2020-02-11 NPDS Signatory Authorization FormNebraska Department of Environmental Quality
NPDES/NPP SIGNATORY AUTHORIZATION FORM
This form is to be used to identify or update information pertaining to the facility. This form must be signed by the
"Cognizant Official. The Cognizant Official' and "Authorized Representative" may be the same person.
Facility Name: - Permit No. NE 0_ _
Address:' City Zip
Location (Street/Directions to) e
Phone
PERMITTEE
List the NAME of the company, business, governmental entity, or person that owns the facility and that will be responsible for the
permit compliance:_16
COGNIZANT OFFICIAL
This person is responsible for the permit, signing reapplications, signing DMRs or designating someone to sign DMRs (Authorized
Representative) and other correspondence. For a municipal, pply the mayor, chairperson or city manager may sign as the
Cognizant Official. Seepage hpo fol' requirements. .
Name_k,kj,na11171 Title
*Mailing Address Z l city
StateZip 0 Phone -{ Home Ph (optional)
AUTHORIZED REPRESENTATIVE (Do not complete if same as Cognizant Official)
This person is designated by the Cognizant Official and is responsible for receiving, completing and signing DMRs, and receiving
other correspondence (i.e., city clerk, plant operator). See page two for requirements.
Name
*Mailing Address . City ids
State Zip Phone Home Ph (optional)
If You Represent this Facility as/fora Contractor, list: Contractor's Name
Contractor's Address Phone
OPERATOR This person is responsible for the operation and maintenance of the plant. See page iipo for requirements.
Name l Title C
Mailing Address ._ Phone tf
If You Represent this Facility as/for a Contractor, list: Contractor's Name
Contractor's Address Phone
*Mailing Address: DMRs will be 'Mailed to this address. DO NOT use home or personal address unless
necessary. Please use city/village office address or facility/corporate address, etc. This address should remain
the same, even with changes in the facility's Cognizant Official or Authorized Representative.
(COMPLETE AND SIGN PAGE 2) Rev0800
0
NPDES/NPP SIGNATORY AUTHORIZATION FORM Page 2 of 2
Facility Name: �� ,- tr°!
ermit. o NR A/ j i 1
SIGNATORY AUTHORIZATION FORM REQUIRMfENTS
Cognizant Official. Nebraska Department of Environmental QuOtty, Title 119, Chapter :l0 and Title 127, Chapter 29
001.01 in the case of a corporation, by a principal executive officer of at least the level of vice:president;'
001.02 in the case of a partnership, by a general partner;...
001.03 in the case of a sole proprietorship, by the proprietor; and
001.04 in the case of a municipal, state or other public facility, by either a principal executive officer or ranking electedofficial.
Authorized Representative. Nebraska Depat ment'ofEnvironmental Quality, Title 119, Chapter 10 andChapi6r 127, Chapter 29
002 All other correspondence, reports and DMRs shall be signed by'a person designated in 001.01 through 001.04 above or a
duly authorized representative. if such a representative is responsible for all the overall operation of the facility from which the
discharge originates; the authorization is made, in writing, by the person designated under 001.01 through 001.04 above, and the
written authorization is submitted to the Director. Any change in the signatures shall be submitted to the Director. Any change' :.
in the signatures shall be submitted to the Director. Any change in the signatures shaft be submitted to the Department, in
writing, within 30 days after the change.
Operator. Nebraska Department of Environmental Quality;.Title i23, Chapter 15
001 A competent operator familiar with the principles of wastewater treatment and disposal and skilled in the operation of the
plant equipment, shall -be in char_ ge of each wastewater works. The operator shall snake such operations tests as may be specified
by the Department.
The operator maybe required to be certified according the NDEQ Title 197:
Nebraska Department of Environmental Quality
ATTN: NPDES Permits & Compliance Units
Sure
1200"N 81tireet, The :A.tr`iuimi
PO Box 98922.
Lincoln, Nebraska 68509-8922
.TelephoO (402) 471:=4220
Fax (402) 4471-2909 Rev08OO