Form DEEP-CPPU-REQUEST-004 "Request to Change Company/Individual Contact Information" - Connecticut

What Is Form DEEP-CPPU-REQUEST-004?

This is a legal form that was released by the Connecticut Department of Energy and Environmental Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 26, 2013;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DEEP-CPPU-REQUEST-004 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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Download Form DEEP-CPPU-REQUEST-004 "Request to Change Company/Individual Contact Information" - Connecticut

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Request to Change Company/Individual Contact Information
Complete this form if there are any changes or corrections to your company/facility or individual mailing or billing address or contact information. If there is a
change in name of the entity holding a DEEP license or a change in ownership, contact the Office of Planning and Program Development (OPPD) at 860-424-
3003. For any other changes you must contact the specific program from which you hold a current DEEP license. Refer to the DEEP contact list at the end of this
form. Send this completed form to Central Permit Processing Unit (CPPU), Department of Energy and Environmental Protection, 79 Elm Street, Hartford, CT
06106-5127. You may contact CPPU at 860-424-4004.
Part I: Requester Information
Requester Name:
Title:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
E-mail:
Part II: Type of Request
Mailing Address or Contact Info Change
Primary Contact Info Change
Billing Address or Contact Info Change
Add a Contact, such as attorney, operator, consultant, etc.
Other (please specify):
If an applicant/registrant/licensee is a corporation, limited liability company, limited partnership, limited liability partnership, or a statutory trust, it must
be registered with the Secretary of State. If applicable, applicant’s/registrant’s name shall be stated exactly as it is registered with the Secretary of
State This information can be accessed at CONCORD.
If an applicant/registrant/licensee is an individual, provide the legal name (include suffix) in the following format: First Name; Middle Initial; Last Name;
Suffix (Jr, Sr., II, III, etc.).
DEEP-CPPU-REQUEST-004
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Rev. 02/26/13
Request to Change Company/Individual Contact Information
Complete this form if there are any changes or corrections to your company/facility or individual mailing or billing address or contact information. If there is a
change in name of the entity holding a DEEP license or a change in ownership, contact the Office of Planning and Program Development (OPPD) at 860-424-
3003. For any other changes you must contact the specific program from which you hold a current DEEP license. Refer to the DEEP contact list at the end of this
form. Send this completed form to Central Permit Processing Unit (CPPU), Department of Energy and Environmental Protection, 79 Elm Street, Hartford, CT
06106-5127. You may contact CPPU at 860-424-4004.
Part I: Requester Information
Requester Name:
Title:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
E-mail:
Part II: Type of Request
Mailing Address or Contact Info Change
Primary Contact Info Change
Billing Address or Contact Info Change
Add a Contact, such as attorney, operator, consultant, etc.
Other (please specify):
If an applicant/registrant/licensee is a corporation, limited liability company, limited partnership, limited liability partnership, or a statutory trust, it must
be registered with the Secretary of State. If applicable, applicant’s/registrant’s name shall be stated exactly as it is registered with the Secretary of
State This information can be accessed at CONCORD.
If an applicant/registrant/licensee is an individual, provide the legal name (include suffix) in the following format: First Name; Middle Initial; Last Name;
Suffix (Jr, Sr., II, III, etc.).
DEEP-CPPU-REQUEST-004
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Rev. 02/26/13
Part II: Type of Request (continued)
Current Data existing on DEEP records
New or Changed Information
Company/Individual Name of Licensee:
Contact OPPD at 860-424-3003 for a name change or change in
ownership.
Mailing Address:
New Mailing Address:
City/Town:
City/Town:
State:
Zip Code:
State:
Zip Code:
Contact Name:
Contact Name:
Contact Title:
Contact Title:
Contact Phone:
Contact Phone:
Contact E-mail:
Contact E-mail:
Billing Address:
New Billing Address:
City/Town:
City/Town:
State:
Zip Code:
State:
Zip Code:
Contact Name:
Contact Name:
Contact Title:
Contact Title:
Contact Phone:
Contact Phone:
Contact E-mail:
Contact E-mail:
Primary Contact Name:
New Primary Contact Name:
Contact Title:
Contact Title:
Address:
Address:
City/Town:
City/Town:
State:
Zip Code:
State:
Zip Code:
Business Phone:
ext.:
Business Phone:
ext.:
E-mail:
E-mail:
DEEP-CPPU-REQUEST-004
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Rev. 02/26/13
Part II: Type of Request (continued)
Current Data existing on DEEP records
New or Changed Information
Contact Name:
New Contact Name:
Contact Title:
Contact Title:
Address:
Address:
City/Town:
City/Town:
State:
Zip Code:
State:
Zip Code:
Business Phone:
ext.:
Business Phone:
ext.:
E-mail:
E-mail:
Part III: DEEP Licenses/Invoices
List all licenses or invoices issued or sent to you by DEEP, which need to be updated with the above information:
License/Invoice Number
License/Invoice Name
DEEP-CPPU-REQUEST-004
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Rev. 02/26/13
Part IV: Certification
The authorized representative and the individual(s) responsible for actually preparing this form must sign this part. This request will be considered incomplete
unless all required signatures are provided.
“I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that based on
reasonable investigation, including my inquiry of the individuals responsible for obtaining the information, the submitted information is true, accurate, and
complete to the best of my knowledge and belief.”
Signature of Authorized Representative
Date
Name of Authorized Representative (print or type)
Title (if applicable)
Signature of Preparer
Date
Name of Preparer (print or type)
Title (if applicable)
Check here if additional signatures are required. If so, please reproduce this sheet and attach signed copies to this sheet.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Program
Phone
Program
Phone
Program
Phone
Air Emissions
860-424-4152
Office of Long Island Sound Program
860-424-3034
Waste Transportation
860-424-3366
Solid Waste Facilities (includes
Water Discharges
860-424-3018
860-424-3366
RCRA Post Closure
860-424-3366
landfills)
Inland Water Resources
860-424-3019
Hazardous Waste TSDF
860-424-3366
Section 22a-454CGS Waste Facilities
860-424-3366
For CPPU Use Only
Request Completed?
Yes
No
Handled By:
Date Entered:
Reason for not completing change:
Requester Notified:
By Phone
By Mail
Date:
Comments:
DEEP-CPPU-REQUEST-004
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Rev. 02/26/13
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