1 

### U.S. Environmental Protection Agency

ELECTRONIC SIGNATURE AGREEMENT

In accepting the electronic signat ure credential issued by the U. S. Environmental Protection Agency (EPA) to sign electronic documents submitted to EPA’s Central Data Exchange (CDX),

and as an authorized official on behalf of:

Electronic Signature Holder Company Information

Parent Company

Name:

Address:

City, State, Zip:

Province:

Country:

Phone Number:

E-mail Address:

Site Name:

Registrant’s Name:

CDX User Name:

I, ________________________________________,

(Name of Electronic Signature Holder)

(1) Agree to protect the electroni c signature credential, consisting of my Central Data Exchange (CDX) user identification and password, from us e by anyone except me. Specifically, I agree to maintain the secrecy of the password; I will not divulge or delegate my user name and password to any other individual; I will not store my passw ord in an unprotected location; and I will not allow my password to be written into com puter scripts to achieve automated login;

(2) Agree to contact the U.S. EPA CDX Help Desk at 1-888-890-1995 as soon as possible, but no later than 24 hours, after susp ecting or determining that my user name and password have become lost, stolen or otherwise compromised;

(3) Understand that I will be informed through my registered electronic mail (e-mail) address whenever my user identification or password have been modified;

(4) Understand that CDX reports the last date my user identif ication and password were used immediately after successf ully logging into CDX;2 (5) Agree that I will review the contents of all electronic submissions prior to submission;

(6) Understand and agree that I will be held as legally bound, obligated, or responsible by my use of my electronic signatur e as I would be using my hand-written signature;

(7) Understand that whenever I electronically sign and submit an electronic document to the CDX, I will receive an e-mail at my registered e- mail address; This e-mail will inform me that a submission has been made to CDX from my user account and will contain instructions to view information regarding the submission, in cluding my Copy of Record (CoR);

(8) Understand that I will receive an e-mail in my CDX inbox with a link to my encrypted, electronically signed copy of my submission;

(9) Agree that if I receive an e-mail notification for a submission that I do not believe that I submitted, I will notify the CDX Help Desk as soon as possible, but no later than 24 hours, after receipt;

(10) Agree to contact the CDX Help Desk if I do not receive an e-mail notification within 5 business days for any electronically si gned submission using my credentials;

(11) Agree to report, within 24 hours of disc overy, any evidence of discrepancy between an electronic document I have signed and submitted and what the CDX has received from me by contacting the CDX Help Desk;

(13) Understand that the Immediate Supervisor or Witnessing Official who signs below may be contacted by the EPA and asked to validate my employment at the company listed above;

(14) Agree to notify the EPA if I cease to repr esent the regulated entity specified above as signatory of that organization’s electronic s ubmissions by contacting the CDX Help Desk as soon as this change in relationship occurs and to sign a surrender certific ation at that time; and,

(15) Agree to retain a copy of this signed agreement as long as I continue to represent the regulated entity specified above as signatory of the company’s electronic submissions.

Name of electronic signature holder: _____________________________

Signature of electronic signature holder: _____________________________

Official Title:

Date: __________________________________

Notary Public: __________________________________3 

### VERIFICATION OF COMPANY AUTHORIZING OFFICIAL

I, acknowledge that the in dividual named above works at/for

(name of supervisor)

a nd is authorized to submit documents and sign the IUR Certification

(name of company)

Statement on the company’s behalf.

Signature of Immediate Supervisor or Witnessi ng Official Date

Official Title

Notary Public: __________________________________

PLEASE SEND THIS DOCUMENT AS SOON AS POSSIBLE TO:

By U.S. Postal Service: By Hand Delivery or Courier:

IUR CDX Registration Coor dinator (7407M) IUR CDX Re gistration Coordinator

U.S. Environmental Protection Agency U.S. EPA- OPPT/RDMB

Office of Pollution Prevention and T oxics EPA East Building, Room 6428 Ariel Rios Building 1201 Constitution Ave, NW 1200 Pennsylvania Ave, NW Washington, DC 20004-3302 Washington, DC 20460 202-564-8956; 202-564-28184 

### AUTHORIZATION AND VERIFICATION OF SUPPORT

SUBMITTER

Authorized Official Signature

I am an authorizing official and an electronic signature holder in U.S. EPA’s CDX for the organization listed below. I verify that the person identified as th e electronic signature holder below is authorized to

submit only support IUR information (i.e., amendments or correspondence) on behalf of my organization.

CDX User ID:

Name of Authorized Official:

Parent Company Name:

Address:

City/Town: County/Parish: State/Province:

Zip/Postal Code: Country:

Signature: Date:

Electronic Signature Holder for Subm ission of Supporting Information

I acknowledge by my signature below that the accuracy of the statements in all electronic submissions reflect my best prediction of the anticipated facts rega rding the chemical substance(s) described therein. Any knowing and willful misrepresentation is subject to criminal penalty pursuant to 18USC 1001. I also acknowledge that I am authorized to submit only support IUR information on behalf of the organization listed above.

CDX User ID:

Name of Electronic Signature

Holder:

Parent Company Name:

Address:

City/Town: County/Parish: State/Province:

Zip/Postal Code: Country:

Site Name:

Address:

City/Town: County/Parish: State/Province:

Zip/Postal Code: Country:

Signature: Date:5 PLEASE SEND THIS DOCUMENT AS SOON AS POSSIBLE TO:

By U.S. Postal Service: By Hand Delivery or Courier:

IUR CDX Registration Coor dinator (7407M) IUR CDX Re gistration Coordinator

U.S. Environmental Protection Agency U.S. EPA- OPPT/RDMB

Office of Pollution Prevention and T oxics EPA East Building, Room 6428 Ariel Rios Building 1201 Constitution Ave, NW 1200 Pennsylvania Ave, NW Washington, DC 20004-3302 Washington, DC 20460 202-564-8956; 202-564-2818