Duly Authorized Representative Form

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Oregon Department of Environmental Quality

NPDES Duly Authorized Representative Form

Permittee Legal Name: ____________________________________________

DEQ Facility/File ID: _____________

Facility Common Name: ___________________________________________

DEQ Permit # ___________________

I hereby certify that I am qualified under 40 §CFR 122.22(a) to be the signatory for NPDES permit applications and I am

appointing the following individuals or named positions to act as Duly Authorized Representatives in accordance with 40

CFR § 122.22(b) for signatures on reports required by NPDES permits and other information requested by DEQ. These

individuals or positions are responsible for the overall operation of the regulated facility or activity, or have overall

responsibility for environmental matters for the company as required by 40 CFR § 122.22(b).

Name w/Position Title or Position Title

Telephone

I understand that if this authorization is no longer accurate because a different individual or position has responsibility for

the overall operation of the facility, I must submit a new authorization form to DEQ prior to or together with any reports

or information signed by the new Duly Authorized Representative.

Signature*: ________________________________________________________________________________________

Print Name: _______________________________________________________________________________________

Title: _________________________________________________________ Date _______________________________

Submit completed form to the appropriate DEQ regional office:

Water Quality Permit Coordinator

DEQ Eastern Region

DEQ Northwest Region

DEQ Western Region

700 SE Emigrant, #330

700 NE Multnomah St., Suite 600

4026 Fairview Industrial Dr.

Pendleton, OR 97801

Portland, OR 97232

Salem, OR 97302

* 1) For a corporation: By a responsible corporate officer. For the purpose of this section, a responsible corporate officer means: (i) A president,

secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar

policy- or decision-making functions for the corporation, or (ii) the manager of one or more manufacturing, production, or operating facilities,

provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the

explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to

assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are

established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign

documents has been assigned or delegated to the manager in accordance with corporate procedures.

2) For a partnership or sole proprietorship: By a general partner or the proprietor, respectively.

3) For a municipality, State, Federal, or other public agency: By either a principal executive officer or ranking elected official. For purposes of this

section, a principal executive officer of a Federal agency includes: (i) The chief executive officer of the agency, or (ii) a senior executive officer

having responsibility for the overall operations of a principal geographic unit of the agency.

4) For a limited liability company: A member.

5) For a trust: Acting trustee.

Rev. 08/21/15 ~ TLB