Change Of Ownership Agreement Form printable pdf download

Change of Ownership Agreement Form

RE: Change of Ownership - VPDES Permit No. __________________

Name of permitted facility: _____________________________________________________________

______________________ County

TO: Virginia Department of Environmental Quality

Regional Office Address

___________________________________________________________________________________

We, the undersigned, hereby request a transfer of ownership for the referenced permit.

Anticipated date of transfer: _______________________________________________

CURRENT OWNER SHOWN ON PERMIT: I (We) hereby agree to the transfer of ownership modification

to the referenced VPDES Permit.

Attach verification that all current owner outstanding Annual Fee payments are up to date (YES/NO). If NO see

statement under NEW OWNER below.

Current Owner name as listed on the VPDES Permit Cover Page:

__________________________________________________________________________________

Signed: ____________________________________________________ Date: _______________________

Printed Name: ______________________________________ Title: ________________________________

Address: ________________________________________________________________________________

__________________________________________________________________________________

[You may add the following consent for electronic transmittal of the termination if you don’t already have it.]

The Department of Environmental Quality (DEQ) may deliver permits and certifications (this includes permit

issuances, reissuances, modifications, revocation and reissuances, terminations and denials) to recipients,

including applicants or permittees, by electronically certified mail where the recipients notify DEQ of their

consent to receive mail electronically (§ 10.1-1183). Check only one of the following to consent to or decline

receipt of electronic mail from DEQ as follows:

Applicant or permittee agrees to receive by electronic mail the permit that may be issued for the proposed

pollutant management activity, and to certify receipt of such electronic mail when requested by the DEQ.

If yes, provide email: ________________________________________________________________________

Applicant or permittee declines to receive by electronic mail the permit that may be issued for the

proposed pollutant management activity.

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(Rev. 3/27/14)

Change Of Ownership Agreement Form