"Name Change and/Or Permit Transfer for Npdes or Wpcf Permit" - Oregon

Name Change and/Or Permit Transfer for Npdes or Wpcf Permit is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on October 10, 2017;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Oregon Department of Environmental Quality.

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Download "Name Change and/Or Permit Transfer for Npdes or Wpcf Permit" - Oregon

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DEQ USE ONLY
DEQ USE ONLY
Oregon Department of Environmental Quality
Application #: _____________
Date Rcvd: _________________
o
Legal name checked
Amt Rcvd: _________________
Name Change and/or Permit Transfer
Notes: ____________________
Check #: ___________________
NPDES or WPCF Permit
_________________________
Rcvd From: ________________
o IND o DOM o STM o OSS
Deposit #: __________________
o UIC:
Receipt #:
A. ACTION TO BE PERFORMED
Name Change / Effective or Scheduled Date:
Transfer of Permit / Scheduled Date:
B. PREVIOUS INFORMATION
1. Previous Legal Name:
Previous Common Name:
2. Facility Physical Address:
3. Permit #:
City, State, Zip Code:
DEQ File#:
County:
C. NEW INFORMATION
1. NEW Legal Name:
2. NEW Common Name:
3. Responsible Official:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
4. Facility Contact:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
5. Invoice to:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
6. Will the name change or transfer of ownership result in a change in the character of pollutants being discharged or a new or
increased discharge not addressed by current permit conditions?
No
Yes (attach explanation)
D. SIGNATURE REQUIRED FOR NAME CHANGE
I herby authorize the above referenced name
change.
___________________________________________
Name of Legally Authorized Representative (Type or Print)
Title
___________________________________________
Signature of Legally Authorized Representative
Date
E. SIGNATURES REQUIRED FOR TRANSFER OF PERMIT
Previous owner:
I hereby acknowledge the pending transfer of the above referenced permit.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
New owner:
I hereby apply for permission to transfer the above referenced permit and certify that I have acquired a property interest
in the permitted activity. I agree to fully comply with all terms and conditions of the permit and DEQ rules.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
last updated: Oct 10, 2017
- 1 -
DEQ USE ONLY
DEQ USE ONLY
Oregon Department of Environmental Quality
Application #: _____________
Date Rcvd: _________________
o
Legal name checked
Amt Rcvd: _________________
Name Change and/or Permit Transfer
Notes: ____________________
Check #: ___________________
NPDES or WPCF Permit
_________________________
Rcvd From: ________________
o IND o DOM o STM o OSS
Deposit #: __________________
o UIC:
Receipt #:
A. ACTION TO BE PERFORMED
Name Change / Effective or Scheduled Date:
Transfer of Permit / Scheduled Date:
B. PREVIOUS INFORMATION
1. Previous Legal Name:
Previous Common Name:
2. Facility Physical Address:
3. Permit #:
City, State, Zip Code:
DEQ File#:
County:
C. NEW INFORMATION
1. NEW Legal Name:
2. NEW Common Name:
3. Responsible Official:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
4. Facility Contact:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
5. Invoice to:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
6. Will the name change or transfer of ownership result in a change in the character of pollutants being discharged or a new or
increased discharge not addressed by current permit conditions?
No
Yes (attach explanation)
D. SIGNATURE REQUIRED FOR NAME CHANGE
I herby authorize the above referenced name
change.
___________________________________________
Name of Legally Authorized Representative (Type or Print)
Title
___________________________________________
Signature of Legally Authorized Representative
Date
E. SIGNATURES REQUIRED FOR TRANSFER OF PERMIT
Previous owner:
I hereby acknowledge the pending transfer of the above referenced permit.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
New owner:
I hereby apply for permission to transfer the above referenced permit and certify that I have acquired a property interest
in the permitted activity. I agree to fully comply with all terms and conditions of the permit and DEQ rules.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
last updated: Oct 10, 2017
- 1 -
NAME CHANGE AND/OR TRANSFER INSTRUCTIONS
A. ACTION TO BE PERFORMED
Check the appropriate box to indicate a name change and/or permit transfer.
¨ For a name change, provide the effective or scheduled date of the name change. Please note that for name changes, DEQ prefers to
process your request after the name has been legally changed to avoid incorrectly modifying its files should the change not occur.
¨ To transfer a permit to a new owner, provide the date on which you want the transfer to occur. Transfer will not occur until DEQ has
received the appropriate signatures and fee and reviewed the transfer information. Approval of a transfer may take up to 30 days to
process.
B. PREVIOUS INFORMATION
1. Enter the previous legal name and common name of this facility or operation if different than the legal name.
2. Enter the facility's physical address (physical location, not mailing address), including city, state, and zip code.
3. Enter the DEQ permit number and facility file number (also known as the site ID number; this number may be found on the first page
of your permit).
C. NEW INFORMATION
1. Enter the new legal name. This name will appear on the permit and must be the legal Oregon name (for example, Acme Products, Inc.)
or the legal representative of the company if the company operates under an assumed business name (for example, John Smith, dba
Acme Products). The name must be a legal, active name registered with the Secretary of State - Corporation Division unless otherwise
exempt by regulation (503-986-2200 or http://sos.oregon.gov/business/Pages/register.aspx).
2. Enter the new common name of this facility or operation if different than the legal name.
3. Enter the name, telephone number, and e-mail and mailing addresses of the Responsible Official. The Responsible Official is the
person that receives official correspondence from DEQ, such as renewal notices or notices of noncompliance, and may be contacted if
there are questions about this application.
4. Enter the name, telephone number, and e-mail and mailing addresses of the Facility Contact if different from the Responsible Official.
The Facility Contact is the person located at the facility that has specific knowledge of the facility or operation under permit (for
example, the treatment plant operator), and may be contacted if there are specific questions about this application.
5. Enter invoicing information for billing purposes if different from new legal name (for example, "Invoice To: Business Office").
6. Complete as indicated. Attach an explanation if changes are being made to the discharge regulated by the current permit.
D. SIGNATURE REQUIRED FOR NAME CHANGE
The signature of a legally authorized representative must be obtained before DEQ will change the name of a permittee.
E. SIGNATURES REQUIRED FOR PERMIT TRANSFER
The signatures of legally authorized representatives from the previous owner and new owner must be obtained before DEQ will transfer
a permit. If the previous owner is not available, DEQ will accept a bill of sale or other proof that the new owner has acquired a property
interest in the permitted activity.
Definition of Legally Authorized Representative:
Please also provide the information requested in brackets [ ]. For NPDES permits, see 40 CFR § 122.22 for more detail.
¨ Corporation – President, secretary, treasurer, vice-president, or any person who performs principal business functions; or a
manager of one or more facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25
million that is authorized in accordance to corporate procedure to sign such documents
¨ Partnership – General partner [list of general partners, their addresses and telephone numbers]
¨ Sole Proprietorship – Owner(s) [each owner must sign the application]
¨ City, County, State, Federal, or other Public Facility – Principal executive officer or ranking elected official
¨ Limited Liability Company – Member [articles of organization]
¨ Trusts – Acting trustee [list of trustees, their addresses and telephone numbers]
FEE AND APPLICATION SUBMITTAL
Please see the cover letter enclosed with this application form or call the appropriate regional office below for fee information and to
determine where to send this application. Send this form and fee to the regional office. Please reference the current
fee table
to
determine the appropriate fees for your permit. Make your check payable to the Department of Environmental Quality.
DEQ Northwest Region
DEQ Western Region
DEQ Eastern Region
700 Lloyd Building at
Onsite Sewage
Stormwater
All Other Permits
800 SE Emigrant, #330
700 NE Multnomah St.,
th
Benton, Lane,
th
165 E 7
Ave, #100
165 E 7
Ave, #100
Pendleton, OR 97801
SE
Suite #600
Lincoln, Linn,
Eugene, OR 97401
Eugene, OR 97401
541-276-4063 or
Marion, Polk,
Salem, OR 9730
Portland, OR 97232
541-686-7838 or
541-686-7838 or
1-800-452-4011
Yamhill
503-378-8240 or
1-800-844-8467
503-229-5263 or
1-800-844-8467
Crook, Deschutes,
Coos, Curry,
1-800-379-7677
1-800-452-4011
381 N 2nd St
Benton, Coos,
Gilliam, Grant,
Douglas (coast)
Coos Bay, OR 97420
Curry, Douglas,
Benton, Coos, Curry,
Harney, Jefferson,
541- 269-2721
Clackamas, Clatsop,
Jackson, Josephine,
Douglas, Jackson,
Klamath, Lake,
Douglas (east)
221 Stewart Ave, #201
Josephine, Lane,
Columbia, Multnomah,
Lane, Lincoln, Linn,
Malheur, Morrow,
Jackson,
Medford, OR 97501
Lincoln, Linn, Marion,
Tillamook, Washington
Marion, Polk,
Wallowa, Umatilla,
Josephine
541-776-6010 or
Polk, Yamhil
Yamhill
Union, Wasco, Wheeler
1-877-823-3216
last updated: Oct 10
17
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