Change Of Ownership Agreement Form (Page 2 of 2) in pdf

NEW OWNER TO ASSUME PERMIT: I (We) hereby agree to the change of ownership modification to the

referenced VPDES Permit, and agree to accept all conditions and responsibilities of the permit.

NEW OWNER agrees to pay all outstanding Annual Fee payments currently due by old owner

YES / NO

Transferred permit to be issued to:

__________________________________________________________________________________

Signed: ____________________________________________________ Date: _______________________

Printed Name: ______________________________________ Title: ________________________________

Address: ________________________________________________________________________________

__________________________________________________________________________________

Telephone: (_____)_______________________

[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.

This form must be signed by properly authorized individuals as specified in the

VPDES Permit Regulation and will not be processed until all fees are up to date.

(Rev. 3/27/14)

Change Of Ownership Agreement Form Page 2