TC_ApplicationSignatureFormForResponsibleParties

DIVISION OF WASTE MANAGEMENT TAX CERTIFICATION APPLICATION RESPONSIBLE PARTY SIGNATURE FORM
NOTICE: The penalty for false statement, representation, or certification herein is imprisonment and fine up to $10,000. N.C.G.S. Sect. 130A-26.2.
Facility Name:
Facility Address:
Application Submittal Date:
(DWM ONLY) TCN Number:
I hereby certify that the equipment, facilities and/or land listed in the tax certification application submitted electronically for the facility listed above to the NC Department of Environmental
Quality on (date) by (name and title of person filling out application) are used for the purpose
stated in the application, and that the information presented in the application is accurate. Furthermore, I certify that any portable or mobile equipment listed on this application will be
used exclusively in the state of North Carolina.
Responsible Party Signature: Date: Print Name, Title, and Company:
I hereby certify that the property listed in the tax certification application submitted electronically for the facility listed above to the NC Department of Environmental Quality on
(date) by (name and title of party responsible for facility compliance) and the facility where
said property is located are in compliance with all local, state, and federal laws and rules for the protection of the environment and are in compliance with the conditions of any permit
issued to the facility by the NC Department of Environmental Quality, any permit issued under Section 404 of the Federal Water Pollution Control Act (33 U.S. Code Section 1344), any
permit issued by a local Air Quality Program, and any permit issued by a local Sedimentation and Erosion Control program.
Responsible Party Signature: Date: Print Name, Title, and Company:
I hereby certify that (name of legal entity receiving tax benefit) has no pending administrative, civil or criminal enforcement action based on alleged
violation(s) of any program implemented by an agency of the N.C. Department of Environmental Quality ("DEQ"), and further certifies that within the last five years there has been no final
determination of responsibility against (name of legal entity receiving tax benefit) for any administrative, civil, or criminal violation of any program
implemented by an agency of DEQ. The undersigned also certifies that (name of legal entity receiving tax benefit) will notify the DEQ Solid
Waste Section Compliance Officer in writing within 60 days of receipt of notification of any administrative, civil or criminal enforcement action based upon alleged violation(s) of any
program implemented by DEQ. I further certify that I have the authority to bind (name of legal entity receiving tax benefit) herein.
Responsible Party Signature: Date: Print Name, Title, and Company:
Signatures on this form must be hand-written/original signatures. Type -written or computer -generated signatures will not be accepted on this form.
Revised 7/8/2022