Delegation Of Authority Form
Download a blank fillable Delegation Of Authority Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Delegation Of Authority Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1ATTACHMENT A - Delegation of Authority Form (Parts 3.2. and 4.15.)
This form is for use by permittees under the MPDES “General Permit for Storm Water
Discharges Associated with Construction Activity”. The owner/operator information and “site
name” provided below must be the same as the information provided on the NOI and SWPPP
Form. This form can be used for an additional and/or new SWPPP Administrator person/position not
identified on the NOI Form.
Delegation of Authority
I, _______________________ (name), hereby designate the person or specifically described
position below to be a duly authorized representative for the purpose of overseeing compliance
with environmental requirements, including the MPDES “General Permit for Storm Water
Discharges Associated with Construction Activity” (General Permit), at the
____________________________________ construction site. The designee is authorized to
sign any reports, Storm Water Pollution Prevention Plan, and all other documents required by
the General Permit.
Name of Person or Position: _____________________________________________________
Owner/Operator:_______________________________________________________________
Mailing Address: ______________________________________________________________
City, State, Zip Code: _____________________________________________________
Phone Number: __________________________________________________________
By signing this authorization, I confirm that I meet the requirements to make such a designation
as set forth in Part 4.15. of the General Permit, and that the designee above meets the definition
of a “duly authorized representative” as set forth in Part 4.15.
I certify under penalty of law that this document and all attachments were prepared under my
direction or supervision in accordance with a system designed to assure that qualified personnel
properly gather and evaluate the information submitted. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the
information, the information submitted is, to the best of my knowledge and belief, true, accurate,
and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name: ________________________________________________________
Title: ________________________________________________________
Signature: ________________________________________________________
____________________________
Date:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business