Application For Transfer Of Permit Or Notification Of Name Change Page 2
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The permit will be transferred. Control of facility has changed or will change (e.g., sale of facility; sale of more than
50% of stock; merger where permittee does not survive) or real property has been or will be transferred by sale or
devise. Both the current permittee and the applicant (proposed new permittee), must complete and sign Part
IV. A fee of $50 shall be submitted with the application for Transfer of Permit by check made payable to the
Department of Environmental Protection (DEP).
PART III. NOTIFICATION OF NAME CHANGE (You checked Box 2.)
TO BE COMPLETED BY CURRENT PERMITTEE (Fill in changes or "no Change" as appropriate.)
New Facility Name: __________________________________________________________________________
New Permittee Name: _______________________________________________________________________
(Company or Legal Entity Name)
Signature: _____________________________________________
Date: ___________________________
(Authorized Representative or Current Permittee)
PART IV: TRANSFER OF PERMIT (You checked Box 3.)
A. TO BE COMPLETED BY THE CURRENT PERMITTEE
The undersigned hereby affirms, under penalty of perjury, that ownership or control of this facility has been or will be
transferred to the applicant below, and also agrees to assign his/her rights as permittee (or authorized representative of
the permittee) to the applicant below if the Department agrees to the transfer of the permit.
Signature: _____________________________________________
Date: ___________________________
(Authorized Representative or Current Permittee)
Type or Print Name: ______________________________________
Title: ___________________________
B. TO BE COMPLETED BY THE APPLICANT (PROPOSED NEW PERMITTEE)
The undersigned hereby affirms, under penalty of perjury, that he/she has or intends to acquire title to or control of this
facility; that he/she has examined the application and documents submitted by the current permittee on which the permit
was based and states that they accurately and completely describe the permitted activity or project; that he/she is familiar
with the permit, agrees to comply with its terms and conditions, and agrees to assume the rights and liabilities set forth in
the permit; and that he/she understands that any substantial changes in the design or operation of the facility will require
a separate permit modification. He/she also agrees to promptly notify the Department of any future changes in ownership
of, or responsibility for, the permitted activity or project. Attach a letter of authorization if you are other than the
owner or corporate officer.
New Permittee: _____________________________________________________________________________
(Company or Legal Entity Name)
Facility name: ________________________________________________________________________________
(As given by Applicant – May remain the same)
Signature: _____________________________________________
Date: ___________________________
(Authorized Representative or Applicant)
Type or Print Name: ______________________________________
Title: ___________________________
Mailing address: _____________________________________________________________________________
(Street or P.O. Box)
(City, State and Zip)
Email: ______________________________________________ Telephone: (____) ________________________
DEP FORM 62-701.900(8)
Effective January 6, 2010
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