Application For Renewal, Amendment Or Cancellation Of Environment Act Permits Form
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1APPLICATION FOR RENEWAL, AMENDMENT OR
CANCELLATION OF ENVIRONMENT ACT PERMITS
Environment
Please complete the following and ensure that all information is legibly printed or typed:
Permittee:
______________________________________________________________________
(Business or individual name)
Permit type:
______________________________________________________________________
(e.g. pesticide, special waste, air emissions, solid waste, land treatment facility, relocation, ODS/OH)
Permit number: ______________________________________________________________________
(e.g. 4201-XX-XXX)
Please check ( 3 ) appropriate box:
Renewal
I have fully reviewed my permit and the information on my current permit is correct and complete
q
and my business is operating as described therein.
Amendment
I have fully reviewed my permit and the following changes or additions have occurred and should
q
be taken into account when renewing my permit (attach additional information if necessary):
Ownership:
______________________________________________________________
Mailing Address:
______________________________________________________________
______________________________________________________________
Site Location(s):
______________________________________________________________
______________________________________________________________
Telephone #:
________________________________ Fax #: ________________________
Email:
______________________________________________________________
Products/Activities: ______________________________________________________________
Transport special wastes: yes:
no:
q
q
Other:
______________________________________________________________
Note: additional information may be required depending on the nature of the change.
Cancellation
I am no longer undertaking the activities authorized by the above permit. I understand that I will
q
be contacted by enforcement officials to confirm that a permit is no longer required, at the following
coordinates:
Mailing Address:
______________________________________________________________
______________________________________________________________
Site Location(s):
______________________________________________________________
______________________________________________________________
Telephone #:
________________________________ Fax #: ________________________
Email:
______________________________________________________________
Permitted Activities: ______________________________________________________________
______________________________________________________________
______________________________________________________________
I, _______________________________________
, certify that I am an authorized
[print name clearly]
representative of ______________________________________
, and hereby make
[business name]
application for the renewal, amendment or cancellation of the above-noted permit, as indicated, and
certify that the information provided on this form is correct.
____________________________
________________________
____________________
Signature of applicant
Date
# of attachments
This information is being collected under the authority of s.90 of the Environment Act. For further information contact the
Environmental Programs Branch at (867) 667-5683.
YG(5694E)E1 Rev. 04/2010
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