Get Duly Authorized Representative Form

Responsible Official/Duly Authorized Representative Identification Form Submit this form to Northwest Clean Air Agency to identify the Responsible Official and/or the Duly Authorized Representative in accordance with Washington Administrative Code WAC 173-401-200-and 520. SECTION B - Partnership or Sole Proprietorship am a general partner in a partnership. am the owner of this sole proprietorship. SECTION C - Municipality state federal or other public agency am a principal executive officer or ranking elected official. My office/title is My agency is A principal executive officer of a federal agency includes the chief executive office having responsibility for the overall operations of a principal geographic unit of the agency e.g. a regional administrator of EPA SECTION D - Signatures Date Duly Authorized Representative Note Completion of this form applies to certification of all AOP reports. Complete one of the following Section A B or C. Sign form in section D. SECTION A - Corporations I certify that I am qualified under the regulatory definition to be the responsible official for the above-named facility. Specifically I am an officer of the corporation. My title is e.g. president secretary treasurer or vice-president of the corporation in charge of a principal business function perform policy or decision-making functions for the corporation similar to that of an officer of the corporation. Explain I hereby designate as a duly authorized representative to act in my stead. This individual s business title is I certify that this individual is responsible for the overall operation of one or more manufacturing production or operating facilities applying for or subject to a permit under these regulations and that the facilities employ more than 250 persons or have gross annual sales or expenditures exceeding 43 million in 1992 dollars or approval of this delegation of authority has been previously requested and given by Northwest Clean Air Agency. Facility Name AOP Number Check if applicable I am submitting this form as notice of an administrative amendment to the existing facility s Air Operating Permit under WAC 173-401-720 1 b. Complete one of the following Section A B or C. Sign form in section D. SECTION A - Corporations I certify that I am qualified under the regulatory definition to be the responsible official for the above-named facility. Specifically I am an officer of the corporation* My title is e*g* president secretary treasurer or vice-president of the corporation in charge of a principal business function perform policy or decision-making functions for the corporation similar to that of an officer of the corporation* Explain I hereby designate as a duly authorized representative to act in my stead* This individual s business title is I certify that this individual is responsible for the overall operation of one or more manufacturing production or operating facilities applying for or subject to a permit under these regulations and that the facilities employ more than 250 persons or have gross annual sales or expenditures exceeding 43 million in 1992 dollars or approval of this delegation of authority has been previously requested and given by Northwest Clean Air Agency.