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Home My WebLink AboutNC0003549 PartialmC 00 0 35tIq) 5T11 &q,aSC0 D. Responsible Official Signature The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate individual with the authority to sign and submit reports for the organization. I, "IcAc, 111a Agreement for (printed name), have the authority to enter into this (Owner/Organization Name). I request the NCDWR grant me and, if included in Sections C and E of this form, the named Submitter(s), an electronic signature credential to submit and accept documents electronically on behalf of my organization. I acknowledge that I, and the individual(s) named in Sections C and E (if applicable), work at/for my organization and have authority to submit and accept electronic documents and act as a signatory for purposes of the NCDWR's electronic document systems. By submitting this application, I, nh, A,- (printed name), have read, understand, and accept the terms and conditions of this Electronic Signature Agreement. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. ) 2� l ResponsitAe Official Signature Title Date RE6-.F,IVE0jN0DEQjDW2 S�o6nse c��rran�rwn�a,gwc.C-en jo`3•$(o()•S311 .JUN 2 7 2019 Email Address Phone Number *email will be the primary method of contact for the electronic submittal process so it is important to have an acctMeWlJality available at all times Permitting Section If you are a current eDMR submitter please provide your User Id: Soo&nzp, . c7�ransiwn ^��:� ¢ _ Con - User Id Subscribed and sworn to before me thisg,--ay of 20. Signat e of Notary Public JUDITH K. KINARD NOTARY PUBLIC STATE OF COLORADO NOTARY ID 19954019422 MY COMMISSION EXPIRES 12/28/2019 (SEAL) Printed Name of Notary Public My Commission Expires NCDWR Electronic Submittal Agreement Version 1 Page 4 E. Submitter Signature The Submitter (electronic signature applicant) is a user other than the Responsible Official who submits this agreement to request to sign reports electronically. The Submitter is given signatory authority by an individual identified as the Responsible Official by the Owner/Organization to sign reports and other information and to accept electronic documents. I, 0L- (lac; :y0\'%M6j\- (printed name), am authorized by the Responsible Official name in this document, who does have the authority under the applicable standards, to enter into this agreement (Owner/Organization Name). By submitting this application, I, (printed name), have read, understand, and accept the terms and conditions of this Electronic Signature Agreement. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. t �►U: fon mEniF.` `m:ti L� T Submittd Signature Title Date RECEIVED/NCDE62/DWit %ahMN, Z-curQ,r 01.Ac0ow� ram_ 363- s60-S3�'�- Email Address Phone Number SUN 2 99 nn *email will be the primary method of contact for the electronic submittal process so it is important to have an accurate efni19 available at all times Water Quality Permitting Section If you are a current eDMR submitter please provide your User Id: Corv— User Id Subscribed and sworn to before me thisaZ diay of 20 . JUDITH K. KINARD NOTARY PUBLIC STATE OF COLORADO NOTARY ID 19954019422 MY COMMISSION EXPIRES 12/28/2019 (SEAL) O Signat e of Notary Public J ud� M- ; e , � ///. 74 r, Printed Name of Notary Public My Commission Expires NCDWR Electronic Submittal Agreement Version 1 Page 5 D. Responsible Official Signature The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate individual with the authority to sign and submit reports for the organization. I, C/� i ��c Di?� �--� (printed name), have the authority to enter into this Agreement for (Owner/Organization Name). I request the NCDWR grant me and, if included in Sections C and E of this form, the named Submitter(s), an electronic signature credential to submit and accept documents electronically on behalf of my organization. I acknowledge that I, and the individual(s) named in Sections C and E (if applicable), work at/for my organization and have authority to submit and accept electronic documents and act as a signatory for purposes of the NCDWR's electronic document systems. By submitting this application, I, C'%,��. .�� W -,,/ (printed name), have read, understand, and accept the terms and conditions of this Electronic Signature Agreement. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. CA✓,•119/7 117•l Responsible Official Signature Title Date cre<� o�#-• . cam Syo-SzSS�3 2 Email Address Phone Number *email will be the primary method of contact for the electronic submittal process so it is important to have an accurate email available at all times If you are a current eDMR submitter please provide your User Id: c'/'e i ci f co--, Subscribed and sworn to before me this H•0 R /V C,`P�O U : REGISTRATION NO. < 7612819 - = MY COMM. EXPIRES; 02/28/2022 \ ' gyp•,.• �: '��i�TARY Pv��G�\\\ ��i0/1111111uO`� (SEAL) User Id 2 � day of � 20 I Signature ANotary Public G ".S-tCL I H-D r r e TG Printed Name of Notary Public My Commission Expires: F G I> 2 9j 2- 0 Z Z NCDWR Electronic Submittal Agreement Version 1 Page 4 E. Submitter Signature The Submitter (electronic signature applicant) is a user other than the Responsible Official who submits this agreement to request to sign reports electronically. The Submitter is given signatory authority by an individual identified as the Responsible Official by the Owner/Organization to sign reports and other information and to accept electronic documents. I, Ae •:4 (printed name), am authorized by the Responsible Official name in this document, who does have the authority under the applicable standards, to enter into this agreement for ,.-P (Owner/Organization Name). By submitting this application, I, C'/.i;-1 le � 4 t1// (printed name), have read, understand, and accept the terms and conditions of this Electronic Signature Agreement. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. 1�1/1-04 orel741 <—elf,I4./i1, Z:;1 ^2f7' /S Submitter Signature Title Date RECEIVED/NCDEQ/DWR cue ,�aP �r7d+�, 'tic . c�� Syo - Szs- S d3 Z Email Address Phone Number JUN 2 7 2Q *email will be the primary method of contact for the electronic submittal process so it is important to have an accurate email available at all times Water Quality Permitting Section If you area current eDMR submitter please provide your User Id: c �e,'�� fi a�srr�a, �4 �,,, e . c • User Id Subscribed and sworn to before me this ��ulnuul�n�, `` ,�P. •moo q< 'A '� REGISTRATION _ 7612819 MY coMM• EXPIRES; 02128120'2 Pr'C.G VIR (SEAL) 2 Lo day of 20 1 CI Signature &Notary Public G►�s-iz. l i-i-a �►-,-c T� Printed Name of Notary Public My Commission Expires: F �Gb Z S j 2,C-)2Z NCDWR Electronic Submittal Agreement Version 1 Page 5