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Vill. Certification of New Permittee <br />"I certify under penalty of law that this document and all attachments were prepared under my direction or <br />supervision in accordance with a system designed to assure that qualified personnel properly gather and <br />evaluate the information submitted. Based on my inquiry of the person or persons who manage the <br />system or those directly responsible for gathering the information, the information submitted is, to the <br />best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant <br />penalties for submitting false information, including the possibility of fine and imprisonment for knowing <br />violations." <br />Printed/Typed Name Company (operator/permittee Title <br />only) <br />Signature of New Operator/Permittee Date <br />* Signature of Operator/Permittee requirements: <br />A. For a corporation: By a responsible corporate officer. <br />B. For a partnership or sole proprietorship: By a general partner or the proprietor, respectively. <br />C. For a municipality, state, federal, or other public facility: By either a principal executive officer or ranking elected <br />official. <br />To request ADA accommodation including materials in a format for the visually impaired, call the Water Quality Program <br />at 360-407-6600 or visit Department of Ecology's Accessibility & the Americans with Disabilities Act (ADA) <br />Webpages. People with impaired hearing may call Washington Relay Service at 711. People with speech disability may <br />call TYY at 877-833-6341. <br />Please sign and email a copy of the completed form and attachments to ecyrewgianoi@ecy.wa.gov, then mail this <br />ORIGINAL document to the following address: <br />Department of Ecology <br />Attn: Water Quality Program, Construction Stormwater <br />PO Box 47696 <br />Olympia, WA 98504-7696 <br />If you have questions, please contact the appropriate permit administrator based on project location. Contact <br />information can be found at: Construction Stormwater General Permit -Washington State Department of Ecology6. <br />S https:Hecology.wa.gov/about-us/accessibility-equity/accessibility <br />6 https:Hecology.wa.gov/regulations-permits/permits-certifications/stormwater-general-permits/construction-stormwater- <br />permit#contact:-:text=Stormwater%20Manuals-,Contact%20information,-Please%20find%20your <br />ECY 020-87a (10/2025) <br />