Delegation of Signature Authority (DSA)
WPDES General Permit Discharge
Form 3400-220 (R 06/19
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Notice: This Delegation of Signature Authority (DSA) form is authorized by s. NR 205.07(1)(g), Wis. Adm. Code, to delegate signature
authority for a Wisconsin Pollutant Discharge Elimination System (WPDES) submittal, which may include a Notice of Intent (NOI or
request for coverage), Notice of Termination (NOT), or other permit compliance document. To delegate signature authority, submittal of
this completed DSA form to the Department of Natural Resources (Department) is mandatory for any permittee, landowner, responsible
executive or municipal officer, manager, partner, or proprietor as specified in s. 283.37(3), Wis. Stats., to be regulated under a WPDES
general permit.
Submission of this DSA constitutes notice that the permittee, landowner, responsible executive or municipal officer, manager, partner,
or proprietor identified in Section II has authorized the person identified in Section III as a duly authorized representative to sign the
WPDES submittal for the landowner, responsible executive or municipal officer, manager, partner, or proprietor. The completed DSA
form shall be submitted as an attachment to the WPDES submittal or when there are any changes to the authorized representative with
the permitted facility or activity.
Note: Submission of a DSA form is not required when the permittee, landowner, responsible executive or municipal officer, manager,
partner, or proprietor signs the WPDES submittal.
Please read all instructions before completing this form, and type or clearly print the information. All necessary information
must be provided on this form. Submission of this DSA constitutes notice that the permittee identified in Section II has
authorized the person identified in Section III to sign the WPDES submittal on behalf of the permittee. Failure to complete this
form correctly will result in the Department’s rejection of the WPDES submittal. Personal information collected will be used for
administrative purposes and may be provided to requesters to the extent required by Wisconsin's Open Records law (ss. 19.31 - 19.39,
Wis. Stats.).
State of Wisconsin
Department of Natural Resources
dnr.wi.gov
Section I: WPDES Submittal Information
WPDES Permit Type:
Concentrated Animal Feeding Operation (CAFO) General Permit No. WI-0063274
Concentrated Animal Feeding Operation (CAFO) Individual Permit No.
Storm Water Construction Site General Permit No. WI-S067831
Storm Water Industrial General Permit No.
Storm Water Municipal (MS4) Permit No.
Storm Water Transportation Construction Activities General Permit No. WI-S066796
Storm Water Transportation TS4 General Permit No. WI-S066800
Wastewater General Permit No.
WPDES Submittal Type:
MS4 or TS4 Annual Report or other permit compliance document
Notice of Intent (NOI)/Permit Application
Notice of Termination (NOT)
Wastewater Electronic Discharge Monitoring Report (eDMR)
Other:
CAFO Plans and Specifications
Nutrient Management Plans
Section II: WPDES Permittee Responsible for Pollutant Discharge
WPDES Permittee (first and last name, title) Individual, Company, Municipality, Organization, or Entity Name
Mailing Address City State ZIP Code
Email Address Phone Number (area code) Alternative Phone Number
Section III: Delegated Signatory Information
Signatory Name (first and last name, title) Individual, Company, Municipality, Organization, or Entity Name
Mailing Address City State ZIP Code
Email Address Phone Number (area code) Alternative Phone Number
