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READY-MIX CONCRETE

MULTIMEDIA GENERAL PERMIT MSG11

READY-MIX CONCRETE

GENERAL PERMIT

FORMS PACKAGE

• READY-MIX CONCRETE NOTICE OF INTENT (RMCNOI) FORM .................... 2

• AIR CONSTRUCTION/MODIFICATION NOTIFICATION FORM........................ 5

• CONTIGUOUS LANDOWNER NOTIFICATION FORM ........................................ 6

• ANNUAL COMPREHENSIVE SITE INSPECTION AND SWPPP EVALUATION

FORM

............................................................................................................................7

• CONSTRUCTION INSPECTION AND CERTIFICATION FORM

..........................

•

REQUEST

FOR

TERMINATI

ON OF CONSTRUCTION EROSION

AND

SEDIMENT CONTROL INSPECTION FORM ........................................................ 10

• MAJOR MODIFICATION F

............................................................................. 11

•

REQUEST

FOR

TRANSFER OF

PERMIT,

GENERAL PERMIT

COVERAGE

AND/

OR NAME CHANGE FORM........................................................................... 12

• REQUEST FOR TERMINATI

ON (RFT) OF COVERAGE FORM......................... 14

These standard forms are used to apply for permit coverage under the Ready-Mix

Concrete General Permit (MSG11) and for submittals and record keeping after

permit coverage has been granted. The forms are in Adobe format on our website

at www.deq.state.ms.us

. Required information can be completed on screen, printed

and signed.

Revised: 03/05/14

Page 1

READY-MIX CONCRETE NOTICE OF INTENT (RMCNOI)

FOR COVERAGE UNDER MULTIMEDIA READY-MIX CONCRETE

GENERAL NPDES PERMIT MSG11

__ __ __ __

(NUMBER TO BE ASSIGNED BY STATE)

FILE AT LEAST 30 DAYS PRIOR TO THE COMMENCEMENT OF THE REGULATED INDUSTRIAL ACTIVITY

INSTRUCTIONS

Applicant must be owner or operator (legal entity that controls the facility’s operation, rather than the plant/site

manager or environmental consultant). The owner or operator that receives coverage is responsible for permit

compliance.

Submittals with this RMCNOI must include:

• A Storm Water Pollution Prevention Plan (SWPPP) addressing storm water associated with industrial activity,

developed in accordance with the requirements of ACT13 of the General Permit

• A detailed site drawing showing the property layout and indicating the features outlined in ACT4, S-2 of the

General Permit

• A United States Geological Survey (USGS) quadrangle map or photocopy, extending at least one-half mile

beyond the facility property boundaries with the site location and outfalls outlined or highlighted. The name of

the quadrangle map must be shown on all copies. Quadrangle maps can be obtained from the MDEQ, Office

of Geology at 601-961-5523

• Plans and specifications for any wastewater treatment facilities necessary to achieve compliance with the

requirements of this permit

Additional submittals that may be required with the RMCNOI:

• A Storm Water Pollution Prevention Plan (SWPPP) addressing storm water associated with construction

activity, developed in accordance with the requirements of ACT19 of the General Permit.

• Appropriate Section 404 documentation

• If storm water discharges associated with construction activity are proposed, a detailed site drawing showing

the property layout and indicating the features outlined in ACT4, S-3 of the General Permit.

• Where previous sampling and analyses have been performed, copies of any existing laboratory data for each

process wastewater outfall and each stormwater outfall. If multiple sampling has been performed, provide a

summary for each parameter, including sampling dates and the minimum, average and maximum values.

ALL QUESTIONS MUST BE ANSWERED (Answer “NA” if not applicable)

OWNER INFORMATION

IS APPLICANT THE OWNER OPERATOR (Check one or both)

OWNER CONTACT NAME & POSITION: _______________________________________________________________________________

OWNER COMPANY NAME: ___________________________________________________________________________________________

OWNER STREET OR P.O. BOX: _______________________________________________________________________________________

OWNER CITY: __________________________________________________________ STATE: ________________ZIP: ________________

OWNER PHONE NUMBER (INCLUDE AREA CODE): ____________________________________________________________________

Revised: 03/05/14

Page 2

OPERATOR INFORMATION

OPERATOR CONTACT NAME & POSITION: ___________________________________________________________________________

OPERATOR COMPANY: ______________________________________________________________________________________________

OPERATOR STREET OR P.O. BOX: ____________________________________________________________________________________

OPERATOR CITY: _____________________________________________________ STATE: _______________ZIP: ___________________

OPERATOR PHONE NUMBER (INCLUDE AREA CODE): ________________________________________________________________

FACILITY INFORMATION

FACILITY NAME: ____________________________________________________________________________________________________

PHYSICAL SITE ADDRESS (IF NOT AVAILABLE INDICATE THE NEAREST NAMED ROAD):

STREET: ________________________________________________ CITY: __________________________________________

COUNTY: ________________________________________________ ZIP: _____________________________________________

NATURE OF BUSINESS (INCLUDE 4 – DIGIT STANDARD INDUSTRIAL CLASSIFICATION CODE (SIC)):

Primary SIC Code: ______________________________ Secondary SIC Code:____________________________________

LIST ANY OTHER PERMITS NEEDED FOR THIS FACILITY: ____________________________________________________________

PLANT PRODUCTION RATE: ________________cubic yards/hr

RECEIVING STREAM: ________________________________________________________________________________________________

STORMWATER ASSOCIATED WITH INDUSTRIAL ACTIVITY

INDICATE ANY ASSOCIATION OR GENERIC SWPPP: ____________________________________________________________________

LIST ANY MATERIAL HANDLING EQUIPMENT, RAW MATERIALS, INTERMEDIATE PRODUCTS, FINAL PRODUCTS, WASTE

MATERIALS, BY-PRODUCTS, OR INDUSTRIAL MACHINERY EXPOSED TO STORM WATER (attach additional pages, if

necessary): _____________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

STORMWATER ASSOCIATED WITH CONSTRUCTION ACTIVITY

(To be completed only for activities in which 1 (one) acre or greater will be disturbed)

PRIME CONTRACTOR NAME: ________________________________________________________________________________________

PRIME CONTRACTOR COMPANY: ___________________________________________________________________________________

PRIME CONTRACTOR STREET OR P.O. BOX: _________________________________________________________________________

PRIME CONTRACTOR CITY: ________________________________________ STATE: _________________ZIP: ___________________

PRIME CONTRACTOR PHONE NUMBER (INCLUDE AREA CODE): ______________________________________________________

TOTAL ACREAGE THAT WILL BE DISTURBED: _______________________________________________________________________

ESTIMATED START DATE: _______________________ ESTIMATED COMPLETION DATE: ______________________

INDICATE ANY LOCAL ORDINANCE REQUIREMENTS: ________________________________________________________________

Revised: 03/05/14

Page 3

Revised: 03/05/14

PROCESS WASTEWATER DISCHARGES

DESCRIBE THE TYPE OF WASTEWATER TREATMENT: __________________________________________________________________

_______________________________________________________________________________________________________________________________________

PROVIDE THE LATITUDE AND LONGITUDE OF EACH WASTEWATER OUTFALL (attach additional pages, if necessary):

LATITUDE: _____ degrees _____ minutes _____ seconds LONGITUDE: _____ degrees _____ minutes _____ seconds

PROVIDE THE PROPOSED FREQUENCY OF DISCHARGE PER OUTFALL: _________________________________________________

_______________________________________________________________________________________________________________________________________

PROVIDE THE PROPOSED VOLUME OF WASTEWATER DISCHARGED PER OUTFALL (gal/day):_____________________________

PROVIDE A MATERIAL SAFETY DATA SHEET ON ALL CHEMICALS USED WHICH POTENTIALLY COULD BE FOUND IN

THE WASTEWATER: ___________________________________________________________________________________________________

AIR EMISSIONS

TYPE OF BATCHING: WET DRY CENTRAL MIX

WILL WATER SPRAYS BE USED AT THE FOLLOWING LOCATIONS? STOCKPILES: YES NO

AGGREGATE BINS: YES NO CONVEYOR TRANSFER POINTS: YES NO

CEMENT SILO INFORMATION: NUMBER OF CEMENT SILOS: ____________________

LOADING METHOD OF SILO: ____________________

VOLUME OF EACH SILO: ________________________cubic yards

FACILITY ROADS WILL BE: PAVED WATER SPRINKLED OTHER (SPECIFY) _____________________________

CUBIC YARDS OF RAW MATERIALS INPUT INTO PLANT:

SAND________________ ROCK___________________ CEMENT __________________

DOES THIS FACILITY UTILIZE ON-SITE ROCK CRUSHERS? YES NO

IF YES, ARE THEY: PERMANENT PORTABLE

NOTE: If this NOI includes the construction of new air emissions sources, the approval to construct will expire if construction does not begin within

eighteen (18) months from the date of coverage issuance or if construction begins and is suspended for eighteen (18) months or more.

CERTIFICATION

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a

system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the

person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is

to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false

information, including the possibility of fine and imprisonment for knowing violations.

________________________________________________________ ___________________________________

Authorized Signature

Date Signed

_________________________________________________________ ___________________________________

Printed Name

Title

This application shall be signed according to ACT25, T-5 of the General Permit, as follows:

- For a corporation, by a responsible corporate officer.

- For a partnership, by a general partner.

- For a sole proprietorship, by the proprietor.

- For a municipal, state or other public facility, by principal executive officer, the mayor, or ranking elected official.

Please submit the RMCNOI form to: Chief, Environmental Permits Division

MS Department of Environmental Quality, Office of Pollution Control

P.O. Box 2261

Jackson, Mississippi 39225

Page 4

READY-MIX CONCRETE GENERAL PERMIT

COVERAGE NUMBER (MSG11 __ __ __ __)

NOTIFICATION OF CONSTRUCTION / MODIFICATION OF AIR EMISSIONS SOURCES

INSTRUCTIONS

In accordance with ACT 7 of the Ready-Mix Concrete General Permit, notifications shall be submitted to MDEQ regarding the start and end

dates of the construction of new air emissions sources or the modification of existing air emissions sources.

Part A of this form shall be used to notify MDEQ of the start of construction or modification, which is due within 15 days of the start of

construction or modification.

Part B of this form shall be used to notify MDEQ of the end of construction or modification, which is due within 30 days of the end of

construction or modification.

For short duration projects, the coverage recipient may complete both Parts A and B on a single submittal, so long as the 15-day construction

start notification and the 30-day end of construction notification deadlines can be met.

COVERAGE RECIPIENT INFORMATION

COMPANY NAME: _______________________________________________ FACILITY NAME: ________________________________________________

FACILITY LOCATION (street address or nearest named road): _____________________________________________________________________________

FACILITY CITY: _________________________________________________ COUNTY: ______________________________________________________

CONTACT PERSON: ______________________________________________ CONTACT PHONE NUMBER: ____________________________________

PART A – Construction Start

Construction / Modification of the air emissions source(s) at the covered facility began on ____________________________, 20_____.

PART B – Construction Complete

Construction / Modification of the air emissions source(s) at the covered facility was completed on ____________________________, 20_____.

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system

designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons

who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge

and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine

and imprisonment for knowing violations.

_____________________________________________________________________ ________________________________________

Authorized Signature

Date

_____________________________________________________________________ ________________________________________

Printed Name Title

Submit this form to:

Chief, Environmental Permits Division

MDEQ, Office of Pollution Control

P.O. Box 2261

Jackson, Mississippi 39225

Revised: 03/05/14

This form shall be submitted with an original signature by an authorized individual in accordance with ACT 25, T-5 or T-6 of the General Permit.

Page 5

Revised: 03/05/14

CONTIGUOUS LANDOWNER NOTIFICATION OF A READY-MIX CONCRETE

FACILITY

I, ____________________________________________, (please print authorized name

of company) am proposing to construct, operate and/or modify a Ready-Mix Concrete

facility at _____________________________________________ (print complete

address with county). The facility processes will include the operation of air emissions

equipment and the discharge of storm water and process wastewater. In addition,

construction activities such as clearing, grading and excavating may also be involved.

This notification is to provide you with an opportunity to comment to the Mississippi

Department of Environmental Quality Permit Board regarding the granting of permit

coverage under the General Permit for Ready-Mix Concrete facilities.

This notice has been sent to you by Certified Mail - Return Receipt Requested. If you

have no comments regarding this proposed facility, no response is necessary and the

permitting process will continue. If you have any comments, they must be received by the

Mississippi Department of Environmental Quality within 10 days of receipt. The

Department of Environmental Quality is limited in its review of this project to those

environmental issues in which statutory authority has been given. Any comments

relative to zoning or economic and social impacts are within the jurisdiction of local

zoning and planning authorities and should be addressed to those authorities. Comments

are to be mailed to the following address:

Chief, Environmental Permits Division

Mississippi Department of Environmental Quality

P. O. Box 2261

Jackson, Mississippi 39225

Page 6

READY-MIX CONCRETE GENERAL PERMIT

COVERAGE NUMBER (MSG11 __ __ __ __)

ANNUAL COMPREHENSIVE SITE INSPECTION AND SWPPP EVALUATION REPORT

(FOR INDUSTRIAL STORM WATER ACTIVITY)

Results of the inspections required by ACT15 of this permit shall be recorded on this report form and submitted annually (postmarked no

later than the 28th day of January for the preceding calendar year). In addition, Appendix A of this form (see back) should be completed

and submitted with this report. Copies of all completed forms shall be retained with the SWPPP. Inspections must be performed monthly.

Resubmittal of the Storm Water Pollution Prevention Plan (SWPPP) for recoverage is not required if the SWPPP is on-site, current and

adequately addresses the sources of pollution at the operation . The coverage number must be listed at the top of all Site Inspection Report

Forms.

COVERAGE RECIPIENT INFORMATION

COMPANY NAME: ________________________________________________ FACILITY NAME: ________________________________________________

FACILITY LOCATION (street address or nearest named road): ________________________________________________________________________________

FACILITY CITY: _________________________________________________ COUNTY: _______________________________________________________

CONTACT PERSON: ______________________________________________ CONTACT PHONE NUMBER: ______________________________________

MAILING ADDRESS: ___________________________________ CITY: ____________________________ STATE: ___________ ZIP: _______________

INSPECTION DOCUMENTATION

ANY DEFICIENCIES?

IF YES, WERE

CORRECTIVE ACTIONS

TAKEN?

DATE

(mm/dd/yy)

TIME

(hh:mm

AM/PM)

Yes No Yes No

INSPECTOR(S)

Deficiencies Noted During any Inspection (give date(s); attach additional sheets if necessary): _____________________________________________________________

______________________

____________

_______________________________________________________________________________________________________

Corrective Action Taken or Planned (give date(s); attach additional sheets if necessary): ________________________________________________________________

_________________________________________________________________________________________________________________________________________

Based upon this inspection which I or personnel under my direct supervision conducted, I certify that all erosion and sediment controls have been implemented and

maintained, except for those deficiencies noted above, in accordance with the Storm Water Pollution Prevention Plan filed with the Office of Pollution Control and sound

engineering practices as required by the above referenced permit. I further certify that the RMCNOI and SWPPP information on file with MDEQ is up to date.

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that

qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons responsible for gathering the information, the

information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false

information, including the possibility of fines and imprisonment for knowing violations.

_______________________________________________________ _____________________________________________________

Authorized Signature Date

_______________________________________________________ _____________________________________________________

Printed Name Title

Please submit this form to: Chief, Environmental Compliance and Enforcement Division

MDEQ, Office of Pollution Control

P.O. Box 2261

Jackson, Mississippi 39225

Revised: 03/05/14

Page 7

APPENDIX A

Annual Comprehensive Site Inspection and SWPPP Evaluation Report

Ready-Mix Concrete General Permit Coverage No. MSG11 __ __ __ __

Air Emissions

What type of air emissions control device is installed on the ready-mix plant or concrete silo? (ACT6)

Baghouse Other, specify: ______________________________________________________________

Is the control device operating correctly? (ACT6) Yes No

Is facility control device repair and maintenance log up to date? (ACT6) Yes No

How are fugitive dust emissions from vehicular traffic controlled? (ACT8) ___________________________________________

________________________________________________________________________________________________________

Are fugitive dust emissions from storage piles and material handling controlled? (ACT8) Yes No

Process Wastewater

Has there been an exceedance of any permit discharge limit during the past 12 months? (ACT12) Yes No

Does the facility have written procedures for the collection, preservation and analysis of treatment

system effluent samples? (ACT11) Yes No

Is there any discharge or runoff of process wastewater, other than through the permitted outfall

from the treatment system? (ACT12) Yes No

Industrial Stormwater

Is the Storm Water Pollution Prevention Plan (SWPPP) on-site? (ACT14) Yes No

Does the SWPPP identify all potential pollutant sources at the facility? (ACT13) Yes No

Is the SWPPP up-to-date and effective at controlling storm water pollutants? (ACT14) Yes No

Are the SWPPP’s Best Management Practices (BMPs) being properly implemented? (ACT14) Yes No

Are additional BMPs needed? (ACT14) Yes No

If additional BMPs are needed, please attach required amendments to SWPPP.

Personnel Training

Does the facility have a program to provide employees initial and annual refresher training

on the requirements of this permit? (ACT23) Yes No

Does the facility maintain documentation of employee training? (ACT23) Yes No

Note: “ACT **” refers to specific sections of the Ready-Mix Concrete General Permit. Revised: 03/05/14

Page 8

FOR CONSTRUCTION STORM WATER ACTIVITY ONLY

Keep a Copy Available at the Permitted Facility or Locally Available

Submit the Inspection Reports Only if Requested by the Mississippi Departmen

t of Environmental Quality (MDEQ)

READY-MIX CONCRETE GENERAL PERMIT

INSPECTION AND CERTIFICATION FORM

COVERAGE NUMBER (MSG11 __ __ __ __)

INSTRUCTIONS

Results of construction storm water inspections required by ACT20, S-4 of this permit shall be recorded on this report form

and kept with the construction storm water SWPPP in accordance with the inspection documentation provisions of ACT21,

R-1 of the this permit. Inspections shall be performed at least weekly for a minimum of four inspections per month. The

coverage number must be listed at the top of all Inspection and Certification Forms.

COVERAGE RECIPIENT INFORMATION

OPERATOR COMPANY NAME: __________________________________________________________________________________________________

FACILITY NAME: ________________________________________________________________________________________________________________

FACILITY STREET ADDRESS: ___________________________________________________________________________________________________

FACILITY CITY: ______________________________________________ FACILITY COUNTY: _________________________________________

OPERATOR MAILING ADDRESS: ________________________________________________________________________________________________

MAILING CITY: _______________________________________________ STATE: _______________________________ ZIP: _______________

CONTACT PERSON: ____________________________________________ CONTACT PHONE NUMBER: _______________________________

INSPECTION DOCUMENTATION

DATE

(mo/day/yr)

TIME

(hr:min AM/PM)

ANY DEFICIENCIES?

(CHECK IF YES) INSPECTOR(S)

Deficiencies Noted During any Inspection (give date(s); attach additional sheets if necessary): __________________________________________

_________________________________________________________________________________________________________________________________________

Corrective Action Taken or Planned (give date(s); attach additional sheets if necessary): ________________________________________________

_________________________________________________________________________________________________________________________________________

Based upon this inspection which I or personnel under my direct supervision conducted, I certify that all erosion and sediment controls have been implemented and

maintained, except for those deficiencies noted above, in accordance with the construction storm water Storm Water Pollution Prevention Plan and sound engineering

practices as required by the above referenced permit. I further certify that the RMCNOI and construction storm water SWPPP information is up to date.

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that

qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons responsible for gathering the information, the

information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false

information, including the possibility of fines and imprisonment for knowing violations.

_______________________________________________________ _____________________________________________________

Authorized Signature Date

_______________________________________________________ _____________________________________________________

Printed Name Title

Revised: 03/05/14

Page 9

REQUEST FOR TERMINATION OF

CONSTRUCTION EROSION AND SEDIMENT CONTROL

INSPECTIONS

(CONSTRUCTION STORM WATER EROSION & SEDIMENT CONTROL INSPECTION REQUIREMENTS ARE FOUND IN

ACT20 OF THE READY-MIX

CONCRETE GENERAL PERMIT)

General NPDES Permit No. MSG11 __ __ __ __ County: _____________________

(Fill in your Certificate of Coverage Number and County)

(Please Print or Type)

I, __________________________________________, (Please Print Authorized Name) certify

that as of _______________________________ (Date), all erosion and sediment controls

were successfully implemented, maintained and completed in accordance with permit

requirements. We do hereby request termination of the weekly erosion and sediment

control inspection requirements.

_________________________ ___________________________ ____________

Owner/Operator

(Please Print) Signature Date

Please submit this form to:

Chief, Environmental Permits Division

MS Department of Environmental Qua

lity

Office

Pollutio

ntrol

P. O. Box 2261

Jackson, Mississippi 39225-2261

Revised: 03/05/14

Page 10

MAJOR MODIFICATION FORM

FOR READY-MIX CONCRETE

GENERAL PERMIT MSG11

INSTRUCTIONS

Coverage recipients shall notify the Mississippi Department of Environmental Quality of plans to expand the acreage or "footprint" of an

existing ready-mix concrete facility or waive the siting criteria of an existing operation. This form must be submitted when one or both of

the following activities is/are being proposed (check all that apply). Copies of the signed Return-Receipts and Contiguous Landowner

Notification Forms shall accompany this Major Modification Form in accordance with ACT4, S-8 of the General Permit.

“Footprint” identified in the original RMCNOI is proposed to be enlarged (a modified SWPPP and an updated USGS topographic

map must be submitted).

Applicant requests waiver of facility siting criteria prescribed in ACTs 5 or 9 of the General Permit.

Applicant intends to construct new air emissions source(s)

This form must be signed by the original coverage recipient under Mississippi's Ready-Mix Concrete General Permit. A different operator

must have general permit coverage transferred prior to coverage being modified. Coverage recipients are authorized to implement the

proposed modifications, under the conditions of the General Permit, only upon receipt of written notification of approval by the MDEQ.

ALL INFORMATION MUST BE COMPLETED (indicate “N/A” where not applicable)

COVERAGE RECIPIENT INFORMATION

COVERAGE RECIPIENT CONTACT PERSON: ____________________________________________________________________________

COMPANY NAME: ___________________________________________________________________________________________________

STREET OR P.O. BOX: ________________________________________________________________________________________________

CITY: __________________________________________________ STATE: __________________ ZIP: __________________

PHONE # (INCLUDE AREA CODE): ____________________________________________________________________________________

PROJECT INFORMATION

READY-MIX CONCRETE GENERAL PERMIT COVERAGE NUMBER: MSG11 __ __ __ __

ADDITIONAL ACREAGE TO BE DISTURBED: ___________________ TOTAL ACREAGE: ______________________

DESCRIBE PROPOSED SITING CRITERIA WAIVER: _____________________________________________________________________

LIST NEW AIR EMISSIONS SOURCES: ___________________________________________________________________

FACILITY NAME: ___________________________________________________________________________________________________

CITY: _________________________________________________ COUNTY: ___________________________________________

I certify under penalty of law that this document and all attachments were prepared

under my direction or supervision in accordance

with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my

inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the

information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant

penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

________________________________________________________ _______________________________________

Signature (must be signed by coverage recipient) Date

___________________________________________________ ___________________________________

Printed Name Title

Please submit this form to: Chief, Environmental Permits Division

MS Department of Environmental Quality, Office of Pollution Control

P.O. Box

2261

Jackson, Mississippi 39225

Revised: 03/05/14

Page 11

Environmental Permits for Industrial Facilities

Request for Transfer of Permit, General Permit Coverage and/or Name Change

Instructions: For Ownership Change-Complete all Items on Page 1 (except Item VIII) and Page 2 (reverse side).

For Name Change Only-Complete Items I, II, V, VI, VII, VIII, and Page 2 (reverse side).

Note-This form should be submitted to MDEQ when a transferal date is finalized but prior to the actual transfer.

Item I.

Facility Name: ___________________________________________________

Location: (Do Not Use P.O. Box)

Street: ___________________________________________________

City: _________________________ State: MS Zip: _____________

County: _________________________________________________

Telephone: (________)_____________________________________

Item II.

Responsible official after transfer or name change:

Name: __________________________________________________________

Title: ___________________________________________________________

Mailing Address:

Street/P.O. Box: ___________________________________________

City: ___________________ State: ______________ Zip: _________

Telephone (________)_________________________________

Item III.

Previous Permittee

: _______________________________________________

Mailing Address:

Street/P.O. Box:___________________________________________

City: _______________________ State: _____ Zip: _____________

Telephone: (________)_____________________________________

Item IV.

New Permittee

: ___________________________________________________

Mailing Address:

Street/P.O. Box:___________________________________________

City: _______________________ State: _____ Zip: _____________

Telephone: (________)_____________________________________

Item V.

Industrial Activity SIC Code: ____________________

Brief Description:

Item VI.

Will Facility Operations Change? Yes __________ No __________

If yes, the appropriate applications and permits may require modification prior

to change.

Item VII.

Will Facility Name Change? Yes______ No______

If Yes, Provide New Name for Permit Coverage.

New Name:______________________________________________________

Item VIII.

Signature for Name Change

Print Name: _____________________________________________________

Authorized Signature

: _____________________________________________

Title: ___________________________________ Date: _________________

Item IX.

We the undersigned request transfer of permit(s) and/or permit coverage(s) listed on the backside of this form.

From:_________________________________________________________

To:___________________________________________________________ Acquisition Date:___________________

By signature below, the recipient certifies that: 1) they are aware of the requirements of the permit(s), 2) the applicant can demonstrate to the Permit

Board it has the financial resources and operational expertise and 3) agrees to accept responsibility and liability for the permit(s) listed on the back of

this document. By signature below, the previous permittee is requesting that the permit(s) and/or permit coverage(s) be transferred to the recipient.

The transfer of the permit(s) or permit coverage(s) will be by written notification from the Office of Pollution Control (OPC). The OPC may require

submittal of information regarding financial capability and past compliance history of the recipient.

__________________________________________________ __________________________________________________

Print New Permittee

Name Print Previous Permittee

Name

__________________________________________________ __________________________________________________

New Authorized Signature

Previous Authorized Signature

________________________________________ _________ ________________________________________ _________

Title Date Title Date

A Permittee is a company or individual that has been issued an individual permit or coverage under a general permit.

Authorized Signature must be owner or in the case of a corporation, a corporate officer as defined in Regulations 11 Miss. Admin. Code Pt. 2, Ch. 2. and 11 Miss.

Admin. Code Pt. 6, Ch. 1.

Page 1 of 2 MARCH 2014

Page 12

Mississippi Department of Environmental Quality/Office of Pollution Control

P.O. Box 2261

Jackson, Mississippi 39225

(601) 961-5171

Item X. Storm Water

(Check One)

___A Storm Water Pollution Prevention Plan (SWPPP) is not required

for the site.

___The recipient certifies that they have received a copy of the Office of

Pollution Control approved SWPPP from the original owner.

___The recipient is submitting a new SWPPP, which is attached to this

form.

___A copy of the SWPPP cannot be obtained from the original owner.

Item XI. Hazardous Waste ID Number

EPA ID No. _______________________________

(Check One)

___An EPA Hazardous Waste ID Number is not required for the site.

___The site’s EPA ID Number is listed above and a Notification of

Regulated Waste Activity Form is attached.

Item XII. Permit(s) and/or Coverage(s) to be Transferred

Permit Type: ___________________________________

Permit/Coverage No.: ____________________________