Request For Transfer Permit Nwd printable pdf download

Florida Department of

Environmental Protection

APPLICATION FOR TRANSFER OF PERMIT

Permit No.______________________________ Date Issued______________________________ Date Expires________________________

NOTIFICATION OF SALE OR LEGAL TRANSFER

Source Name:__________________________________________________________County:_ ____________________________________

Source Location:____________________________________________________________City:____________________________________

Permittee Name:___________________________________________________________Title:_____________________________________

Mailing Address:____________________________________________________________________________________________________

______________________________________________________ Telephone (_____)____________________________________________

The undersigned hereby notifies the department of the sale or legal transfer of this pollution source. He further agrees to assign his rights as

permittee to the applicant in the event the department agrees to the transfer of permit.

Sworn to and subscribed before me at ___________________ ________________________________________________________________

Signature of Permittee

County, ___________________________________, _______________________________________________________________________

Title

this __________ day of _____________________ 20_____ Date: _____________________________________________________________

_____________________________________________________________

Notary Public

My Commission expires: ________________________________________

REQUEST FOR TRANSFER PERMIT

Source Name:________________________________________________________________________________________________________

Applicant Name:______________________________________________________________________________________________________

Mailing Address: _____________________________________________________________________________________________________

______________________________________________________ Telephone (_____)______________________________________________

Project Engineer: Name:________________________________________________________________________________________________

Mailing Address:______________________________________________________________________________________________________

______________________________________________________ Telephone (_____)______________________________________________

The undersigned hereby notifies the department of his having acquired title to this pollution source. He further states that he has examined the

application and documents submitted by the current permittee the basis on which Permit No.________________________________________

was issued by the department, and states that they accurately and completely describe the permitted activity or project. He further states that he

is familiar with the permit, agrees to comply with its terms and conditions, and agrees to assume the rights and liabilities contained therein. He

also agrees to promptly notify the department of any future change in ownership of, responsibility for, the permitted activity project.

Sworn to and subscribed before me at ___________________ _________________________________________________________________

Signature of Applicant*

County, ___________________________________, ________________________________________________________________________

Title

this __________ day of _____________________ 20_____ Date:_______________________________________________________________

____________________________________________________________

Notary Public

My Commission expires:________________________________________

*Attach letter of authorization if other than owner or corporate officer.

DEP FORM 62-1.201(1) Effective November 30, 1982

Request For Transfer Permit Nwd