2014-04-17 NPDES 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: Blair Waste Water Treatment Plant Permit No. NE 0021482
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Address: 850 East Fairview Drive City Blair Zip 68008
Location (Street/Directions to)
Phone 402 - 426 -4191
PERNUTTEE
List the NAME of the company, business, governmental entity, or person that owns the facility and that will be responsible for
the permit compliance:
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, only the mayor, chairperson or city manager may sign as
the Cognizant Official. Seepage two for requirements.
Name James Realph
*Mailing Address 218 South 16 Street
State Nebraska Zip 68008 Phone 402 - 426 -4191
Title Mayor
City Blair
Home Ph
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). Seepage two for requirements.
Name Allen Schoemaker Title Director of Public Works
*Mailing Address 218 South 16 Street City Blair
State Nebraska Zip 68008 Phone 402 - 426 -4191 Home Ph (optional)
If You Represent this Facility as /for a Contractor, list: Contractor's Name
Contractor's Address Phone
OPERATOR This person is responsible for the operation and maintenance of the plant. Seepage two for requirements.
Name Robert Frahm Title Supervisor
Mailing Address 218 South 16 Savo Blair, Nebraska 68008 Phone 402 -426 -5818
IfYouR tthisFaci *as/foraConftuctor,list Contraetar'sName
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
NPDES /NPP SIGNATORY AUTHORIZATION FORM Page 2 of 2
Facility Name: Blair Wastewater Treatment Plant Permit No. NE0021482 ___________ ____________________________ ___
COAMENTS
I'
COGNIZANT OFFICIAL
SIGNATUR 6,,
DATE
James Re 1ph, Mayor
ylnliY
PRINTED NAME OF COGNIZANT 0 F AL
SIGNATORY AUTHORIZATION FORM REQUIREMENTS
Cognizant Official. Nebraska Department of Environmental Quality, Title 119, Chapter 10 and Title 127, Chapter 29
00 1.0 1 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 elected official.
Authorized Representative. Nebraska Department of Environmental Quality, Title 119, Chapter 10 and Chapter 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 shall be submitted to the Department,
in writing, within 30 days after the change.
Operator. Nebraska Department of Environmental Quality, Title 123, 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 charge of each wastewater works. The operator shall make such operations tests as may be
specified by the Department.
The operator may be required to be certified according the NDEQ Title 197.
Nebraska Department of Environmental Quality
ATTN: NPDES Permits & Compliance Units
Suite 400,1200 N Street, The Atrium
PO Box 98922
Lincoln, Nebraska 68509 -8922
Telephone (402) 471 -4220
Fax (402) 471 -2909 Rev08OO