UIC/ME Signatory Authorization Form
This information is provided by the Nebraska Department of Environment and Energy to assist the public and regulated community.
Form #: WAT148 Applications and Forms Revised: 11/1/09
SizeFile Name
56 KB SignatoryForm-UIC-ME.pdf

Note: Effective Oct. 1, 2009, any individual submitting any application or form that would derive public benefit from the state must also fill out a United States Citizenship Attestation form. This applies to individuals submitting the forms on their own behalf. If applicable, please fill out the United States Citizenship Attestation form below and submit it with the relevant applications and forms.

United States Citizenship Attestation Form

This Complete Form is only available as an Adobe Acrobat (PDF) file.
File size is 97 KB

This form is to be used to identify or update information pertaining to the facility. This form must be signed by the “Cognizant Official.