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Form Submittal: PERMIT TRANSFER APPLICATION Forms may be (Maricopa County Telecommunications)

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Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
PERMIT TRANSFER APPLICATION
Revised 23 January 2020
Form Submittal
Forms may be submitted by email. After completing the form electronically, save it to your computer, then attach and email the form to
AQPermits@maricopa.gov.
Forms may also be submitted in person or mailed to either of the following locations:
1. Maricopa County Air Quality Department, 3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
2. One Stop Shop, 501 N. 44th St., Suite 200, Phoenix, AZ 85008
Email will be the departments primary means for routine communication with you, unless you do not have an email account. Please be
sure that your email address is entered correctly. Use this form only to transfer ownership of a current air quality permit. Submit the
completed Permit Transfer Application to Maricopa County Air Quality Department (MCAQD) at least 30 days before the proposed
ownership transfer. Please note that any applicable fees must be paid before MCAQD can approve the application. If you are only
changing the name of a business, please complete a Contact Information Update Form in lieu of the Permit Transfer Application.
Existing Facility ID:
Expiration Date:
Existing Business Name:
Site Address: City: State: Zip:
Existing Owner Name: Existing Owner Contact:
Existing Owner Address: City: State: Zip:
Phone Number: Mobile: Email:
New Business Name (if different from existing name):
Specific date for the transfer of permit responsibility, coverage, and liability between the current and new permitee:
New Property Owner Information (provide the legal name of person, corporation, partnership, or other entity)
Property Owner Name:
Address: City: State: Zip:
Title:
Provide qualifications and information about the new owner's capabilities for operating the source (attach statement, if needed):
Phone Number: Mobile: Email:
Contact Name:
Contact Name: Title:
Address: City: State: Zip:
Mobile Phone:Phone Number: Email:
New On-Site Operator Contact (designated contact at the facility, principally responsible for the operation of the source)
New Permitting Contact (will receive documents from Air Quality such as invoices, permits and renewals)
Contact Name: Title:
Address: City: State: Zip:
Phone Number:
Mobile Phone: Email:
Example: I have been a business owner for 2 years. I have worked in this industry for 5 years.
Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
PERMIT TRANSFER APPLICATION
Revised 23 January 2020
The equipment to be transferred is identical to the equipment listed under the current permit. - OR -
The equipment list has changed. Provide a complete description of the new/changed equipment (attach additional list if necessary).
Equipment
Make & Model Quantity Comments
Have there been any enforcement action(s), related to the protection of the environment, instituted in the last five years against any
person(s) employed by the new permittee who was principally responsible for operating the source?
Date Action Result
No Yes. List the date, action, and result below. Attach additional list if necessary.*
*In lieu of this description, the new permittee must submit a copy of the certificate of disclosure or 10-K form required under A.R.S.
§49-109, or a statement that this information has been filed in compliance with A.R.S. §49-109.
Notice of Regulatory Reform in accordance with A.R.S. §11-1604:
A. A county shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule, ordinance or
delegation agreement. A general grant of authority does not constitute a basis for imposing a licensing requirement or condition unless the authority specifically authorizes
the requirement or condition.
B. Unless specifically authorized, a county shall avoid duplication of other laws that do not enhance regulatory clarity and shall avoid dual permitting to the maximum
extent practicable.
C. This section does not prohibit county flexibility to issue licenses or adopt ordinances or codes.
D. A county shall not request or initiate discussions with a person about waiving that person's rights.
E. This section may be enforced in a private civil action and relief may be awarded against a county. The court may award reasonable attorney fees, damages and all fees
associated with the license application to a party that prevails in an action against a county for a violation of this section.
F. A county employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the
county's adopted personnel policy.
G. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
Certification by the Current Permit Holder (Transferor):
I certify that the information provided in this application and accompanying documents is true, correct, and complete to the best of my
knowledge. I acknowledge that all fees, due and past due, will need to be paid before MCAQD will approve the permit transfer.
Signature: Date Signed:
I intend to transfer the responsibility, coverage and liability of this permit to the New Permit Holder on this date:
Type or Print Name: Title: Company:
Certification by the New Permittee (Transferee):
I certify that the information provided in this application and accompanying documents is true, correct, and complete to the best of my
knowledge. I certify that the new permittee is financially capable of operating the source in compliance with the law. I acknowledge that all
fees, due and past due, will need to be paid before MCAQD will approve the permit transfer.
Signature: Date Signed:
I intend to accept the responsibility, coverage, and liability of this permit as the New Permittee on this date:
Type or Print Name: Title: Company:
Office Use Only
Approved By: Date:
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Form Submittal: PERMIT TRANSFER APPLICATION Forms may be (Maricopa County Telecommunications)

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Completed 6 August 2020

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