DEQ USE ONLY
File #:
Application #:
EPA #:
ACD Fee Paid:
DOC Conf.:
Notes:
| DEPARTMENT OF ENVIRONMENTAL QUALITY
NAME CHANGE AND/OR
PERMIT TRANSFER
FOR NPDES* OR WPCF** PERMIT
*National Pollutant Discharge Elimination System
**Water Pollution Control Facilities | DEQ USE ONLY
Received:
Amount Received:
On-Site Surcharge:
Check #:
Deposit #:
o IND o DOM o OSS o UIC:
Notes: |
| | |
| A. ACTION TO BE PERFORMED |
| [ ] Name Change / Effective or Scheduled Date: | [ ] Transfer of Permit / Scheduled Date: |
| B. PREVIOUS INFORMATION |
| 1. Previous Legal Name: |
| 2. Previous Common Name: |
| 3. DEQ Facility ID #:
Permit #: | 4. Facility Physical Address:
City, State, Zip Code: |
| C. NEW INFORMATION |
| 1. New Legal Name: |
| 2. New Common Name: |
| 3. Responsible Official: Telephone #: Email:
Mailing Address: City, State, Zip Code: |
| 4. Facility Contact: Telephone #: Email:
Facility Mailing Address: City, State, Zip Code: |
| 5. Invoice to: Telephone #: Email:
Billing Address: City, State, Zip Code: |
| 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 hereby 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 the rules of the Environmental Quality Commission. |
|
Name of Legally Authorized Representative (Type or Print) |
Title |
|
Signature of Legally Authorized Representative |
Date |
NAME CHANGE AND PERMIT 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, the Department 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 the Department 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.
2. Enter the common name of this facility or operation if different than the legal name.
3. Enter the DEQ facility identification number (also known as the site or file number; this number may be found on the first page of your permit) and the permit number.
4. Enter the facility's physical address (physical location, not mailing address), including city, state, and zip code.
C. NEW INFORMATION:
1. Enter the new legal name. This name will appear on the permit and must be the legal Oregon name (i.e., Acme Products, Inc.) or the legal representative of the company if the company operates under an assumed business name (i.e., John Smith, dba Acme Products). The name must be a legal, active name registered with the Oregon Department of Commerce, Corporation Division (503) 378-4752 (http://www.filinginoregon.com), unless otherwise exempted by their regulations.
2. Enter the 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 (e.g., 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 (e.g., "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 the Department 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 the Department will transfer a permit. If the previous owner is not available, the Department 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:
See 40 CFR 122.22 for more detail. Also, please also provide the information requested in brackets [ ] |
• 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:
The fee to perform a name change and/or transfer a permit depends on the type of permit. The fees are as follows:
• $132 for WPCF onsite sewage system permit ($72 Table 9D application filing fee plus $60 Table 9F department surcharge)
• $82 for any other WPCF or NPDES permit
Send this form and fee to the appropriate DEQ regional office.
Make your check payable to the Department of Environmental Quality. |
DEQ Northwest Region
2020 SW 4th Ave., Suite 400
Portland, OR 97201-4987
(503) 229-5263 or
1-800-452-4011 inside Oregon | DEQ Western Region | DEQ Eastern Region
700 SE Emigrant, Suite 330
Pendleton, OR 97801
(541) 276-4063 or
1-800-304-3513 inside Oregon |
| | Stormwater and Onsite Sewage Permits:
165 E. 7th Ave.,Suite 100
Eugene, OR 97401
(541) 686-7838 or
1-800-844-8467 inside Oregon | All Other Permits:
750 Front St. NE Suite 120
Salem, OR 97301-1039
(503) 378-8240 or
1-800-379-7677 inside Oregon | |