"Application for Permit Transfer and Application for Transfer of Pending Application" - New York

Application for Permit Transfer and Application for Transfer of Pending Application is a legal document that was released by the New York State Department of Environmental Conservation - a government authority operating within New York.

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Application For Permit Transfer
and Application for Transfer of Pending Application
NOTE: Please read ALL instructions before completing
this application. Please TYPE or PRINT clearly in ink.
PART 1 - TRANSFEREE (New Owner/Operator/Lessee/Applicant) Completes:
1. List Permit Number(s) And Their Effective And Expiration Dates:
List Pending Application Number(s):
2. Name Of Transferee:
Telephone Number (Daytime):
Transferee is a/an: (check all that apply)
(
)
Owner
Operator
Mailing Address:
Email:
Lessee
Applicant
If other than an individual, provide
Post Office City, State, Zip Code:
Taxpayer ID Number:
3. Name Of Facility/Project:
4. Facility Contact Name:
Telephone Number (Daytime):
(
)
Location (or Street Address, P.O. City, State, Zip Code, if applicable):
Mailing Address:
Email:
Town / Village / City:
County:
Post Office City, State, Zip Code:
5. Has Work Begun On The Project?
Yes
No
If “No,” proposed starting date: ___________________________ Approximate completion date:_________________________
If there will be any modifications to the current or proposed operation or construction, the transferee must attach a statement specifying the details.
6. CERTIFICATION: This certifies that the Transferee seeks to be the legally responsible party for operations or project development either
authorized by the permits identified above or proposed in applications identified above. The Transferee has a copy of the permit(s) and/or
application(s) and understands and will comply with all conditions in the referenced permit(s) and supports the content of referenced application(s).
Facility operations/project scope/discharges/emissions will remain the same as authorized or as proposed in pending applications. Further, I
hereby affirm that under penalty of perjury that information provided on this form and all attachments submitted herewith is true to the best of my
knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
Printed Name and Title of Transferee _________________________________________________________________________________________
Signature of Transferee _______________________________________________________________________ Date________________________
PART 2 - TRANSFEROR (Present or Former Owner/Operator/Lessee/Applicant) Completes:
1. Name Of Transferor:
Telephone Number (Daytime):
If other than an individual, provide
(
)
Taxpayer ID Number:
Mailing Address:
Email:
Post Office City, State, Zip Code:
2. Name Of Facility/Project, if different from Facility Name in Part 1:
3. CERTIFICATION: This certifies that ownership, operation, or a lease for the facility identified in Part 1 of this form
will be /
was conveyed to
the party identified as the Transferee on _____________________________ (date). I affirm that this conveyance includes the rights and
obligations of the permits, approvals, or applications identified above.
Printed Name and Title of Transferor _________________________________________________________________________________________
Signature of Transferor ________________________________________________________________________ Date_______________________
PART 3 - PERMIT TRANSFER VALIDATION SECTION - Department Of Environmental Conservation Completes:
Transfer of permit approved, effective as of ___________________. Transferee subject to conditions of original permit, without exception.
Transfer of permit approved, with the following modifications or contingencies related to this Permit Transfer:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
See attached revised permit page(s): _________________________________________________________________________________
Transfer of application approved. See attached for additional information required.
Transfer denied, new application required. Please complete the enclosed permit application and return it to the undersigned Regional Permit
Administrator at the address listed on the reverse side of this form.
__________________________________________
___________________________________________________ __________________
NYSDEC PERMIT ADMINISTRATOR
SIGNATURE
DATE
copies to:
(rev. 8/16)
RESET
Application For Permit Transfer
and Application for Transfer of Pending Application
NOTE: Please read ALL instructions before completing
this application. Please TYPE or PRINT clearly in ink.
PART 1 - TRANSFEREE (New Owner/Operator/Lessee/Applicant) Completes:
1. List Permit Number(s) And Their Effective And Expiration Dates:
List Pending Application Number(s):
2. Name Of Transferee:
Telephone Number (Daytime):
Transferee is a/an: (check all that apply)
(
)
Owner
Operator
Mailing Address:
Email:
Lessee
Applicant
If other than an individual, provide
Post Office City, State, Zip Code:
Taxpayer ID Number:
3. Name Of Facility/Project:
4. Facility Contact Name:
Telephone Number (Daytime):
(
)
Location (or Street Address, P.O. City, State, Zip Code, if applicable):
Mailing Address:
Email:
Town / Village / City:
County:
Post Office City, State, Zip Code:
5. Has Work Begun On The Project?
Yes
No
If “No,” proposed starting date: ___________________________ Approximate completion date:_________________________
If there will be any modifications to the current or proposed operation or construction, the transferee must attach a statement specifying the details.
6. CERTIFICATION: This certifies that the Transferee seeks to be the legally responsible party for operations or project development either
authorized by the permits identified above or proposed in applications identified above. The Transferee has a copy of the permit(s) and/or
application(s) and understands and will comply with all conditions in the referenced permit(s) and supports the content of referenced application(s).
Facility operations/project scope/discharges/emissions will remain the same as authorized or as proposed in pending applications. Further, I
hereby affirm that under penalty of perjury that information provided on this form and all attachments submitted herewith is true to the best of my
knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
Printed Name and Title of Transferee _________________________________________________________________________________________
Signature of Transferee _______________________________________________________________________ Date________________________
PART 2 - TRANSFEROR (Present or Former Owner/Operator/Lessee/Applicant) Completes:
1. Name Of Transferor:
Telephone Number (Daytime):
If other than an individual, provide
(
)
Taxpayer ID Number:
Mailing Address:
Email:
Post Office City, State, Zip Code:
2. Name Of Facility/Project, if different from Facility Name in Part 1:
3. CERTIFICATION: This certifies that ownership, operation, or a lease for the facility identified in Part 1 of this form
will be /
was conveyed to
the party identified as the Transferee on _____________________________ (date). I affirm that this conveyance includes the rights and
obligations of the permits, approvals, or applications identified above.
Printed Name and Title of Transferor _________________________________________________________________________________________
Signature of Transferor ________________________________________________________________________ Date_______________________
PART 3 - PERMIT TRANSFER VALIDATION SECTION - Department Of Environmental Conservation Completes:
Transfer of permit approved, effective as of ___________________. Transferee subject to conditions of original permit, without exception.
Transfer of permit approved, with the following modifications or contingencies related to this Permit Transfer:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
See attached revised permit page(s): _________________________________________________________________________________
Transfer of application approved. See attached for additional information required.
Transfer denied, new application required. Please complete the enclosed permit application and return it to the undersigned Regional Permit
Administrator at the address listed on the reverse side of this form.
__________________________________________
___________________________________________________ __________________
NYSDEC PERMIT ADMINISTRATOR
SIGNATURE
DATE
copies to:
(rev. 8/16)
RESET
Application for Permit Transfer and Application for Transfer of Pending Application
General Instructions
This form is to be used for transferring valid permits and pending applications for permit from a present permit holder or applicant (Transferor) to
another party taking responsibility as a permittee or applicant (Transferee).
Legally Responsible Party means a permittee lawfully accountable for undertaking a permitted action in accordance with the provisions and
conditions of a permit, or an applicant lawfully accountable for the content of an application.
The Transferee (New Owner/Operator/Lessee/Applicant) must:
1.
Complete Part 1 of this application form.
2.
Have Part 2 of this applicant form completed by the Transferor (former Owner/Operator/Lessee/Applicant). If the information requested in
Part 2 cannot be obtained, the Transferee must attach a statement giving the reason(s).
3.
Submit completed application form to the Regional Permit Administrator, Division of Environmental Permits, at the appropriate office of the
department (see map below).
Other Instructions
4.
Applications by a Corporation shall be signed by a member of the board of directors or a “high managerial agent” of the corporation as that
term is defined in the § 20.20 of the Penal Law; a Partnership by a general partner; a Sole Proprietorship by the proprietor; a Municipality or
Public Corporation by the duly authorized principal executive officer; and a State Agency by a person duly designated by the commissioner
or other agency head. Applications by a Limited Liability Company shall be signed by a member or manager in accordance with the LLC’s
articles of organization as filed with the Secretary of State.
5.
If other than the owner makes application, written consent of the owner to use the property/facility must accompany the application.
6.
The Transferee is responsible for obtaining any other required federal, state or local permits.
7.
The department may request additional information in accordance with the Record of Compliance Enforcement Guidance Memorandum, or
with regard to financial assurance guaranties.
8.
If available, attach a copy of the first page of the permit(s) requested for transfer.
Contact the Regional Permit Administrator, Division of Environmental Permits, at the appropriate office of the department, as given below, for
assistance regarding any of the above requirements.
NYS Department of Environmental Conservation
NYS DEC REGION 7
NYS DEC REGION 4 Sub-Office
www.dec.ny.gov
Regional Permit Administrator
Regional Permit Administrator
615 Erie Blvd West, Room 206
65561 State Highway 10
Syracuse, NY 13204-2400
Stamford, NY 12167-9503
315-426-7438
fax: 315-426-7425
607-652-7741
fax: 607-652-2342
DEP.R7@dec.ny.gov
DEP.R4@dec.ny.gov
email:
email:
< For Delaware and Otsego Counties
NYS DEC REGION 7 Sub-Office
Regional Permit Administrator
1285 Fisher Avenue
NYS DEC REGION 5
Cortland, NY 13045-1090
Regional Permit Administrator
607-753-3095 ext. 233
PO Box 296
fax: 607-753-8532
DEP.R7@dec.ny.gov
email:
1115 NYS Route 86
Ray Brook, NY 12977-0296
< For Broome, Chenango, Cortland,
518-897-1234
fax: 518-897-1394
Madison, Tioga and Tompkins
DEP.R5@dec.ny.gov
email:
Counties
NYS DEC REGION 5 Sub-Office
NYS DEC REGION 8
Regional Permit Administrator
Regional Permit Administrator
232 Golf Course Rd
6274 East Avon - Lima Road
Warrensburg, NY 12885-1172
Avon, NY 14414-9519
518-623-1282
fax:518-623-3603
< Counties/Areas served by the DEC
DEP.R5@dec.ny.gov
585-226-5400
fax: 585-226-2830
< For
email:
Regional
Sub-Office
are
listed
DEP.R8@dec.ny.gov
email:
Fulton, Saratoga, Warren, and
below their contact information.
For
all
other
Counties/Areas,
Washington, Counties
contact the DEC Regional Office.
NYS DEC REGION 6
NYS DEC REGION 9
NYS DEC REGION 1
NYS DEC REGION 3
Regional Permit Administrator
Regional Permit Administrator
Regional Permit Administrator
Regional Permit Administrator
Dulles State Office Building
270 Michigan Avenue
SUNY @ Stony Brook
21 South Putt Corners Road
317 Washington Street
Buffalo, NY 14203-2915
50 Circle Road
New Paltz, NY 12561-1620
Watertown, NY 13601-3787
716-851-7165
fax: 716-851-7168
Stony Brook, NY 11790-3409
845-256-3054
fax: 845-255-4659
DEP.R9@dec.ny.gov
315-785-2245
fax: 315-785-2242
email:
DEP.R3@dec.ny.gov
DEP.R6@dec.ny.gov
631-444-0365
fax: 631-444-0360
email:
email:
DEP.R1@dec.ny.gov
email:
NYS DEC REGION 9 Sub-Office
NYS DEC REGION 6 Sub-Office
Regional Permit Administrator
NYS DEC REGION 2
NYS DEC REGION 4
Regional Permit Administrator
182 East Union, Suite 3
Regional Permit Administrator
Regional Permit Administrator
Utica State Office Building
Allegany, NY 14706-1328
1 Hunter's Point Plaza
1130 North Westcott Road
207 Genesee Street, Room 1404
716-372-0645
fax: 716-372-2113
47-40 21st Street
Schenectady, NY 12306-2014
Utica, NY 13501-2885
DEP.R9@dec.ny.gov
email:
Long Island City, NY 11101-5407
518-357-2069
fax: 518-357-2460
315-793-2555
fax: 315-793-2748
< For Allegany, Cattaraugus, and
DEP.R4@dec.ny.gov
email:
DEP.R6@dec.ny.gov
718-482-4997
fax: 718-482-4975
email:
DEP.R2@dec.ny.gov
Chautauqua Counties
email:
< For Herkimer, and Oneida Counties
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