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Transfer of Ownership Agreement Form
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
(Please Type or Print All Information)
Instructions: This agreement form must be signed in INK by properly authorized individuals as specified in the General
VPDES Permit for Stormwater Discharges from Construction Activities (VAR10), Part III K (Signatory Requirements).
Please retain a copy of this agreement form for your records.
Mail the original agreement form to:
Department of Environmental Quality
Office of Stormwater Management, 10th Floor
P.O. Box 1105
Richmond, VA 23218
General Permit Registration Number: Date of Transfer (mm/dd/yyyy):
Construction Activity Name:
CURRENT CONSTRUCTION ACTIVITY OPERATOR:
Name:
Contact:
Mailing Address:
City: State: Zip: Phone:
Email Address (if available):
“I (We) hereby agree to the transfer of ownership modification to the referenced General VPDES Permit for Discharges of
Stormwater from Construction Activities (VAR10).”
Printed Name: Title:
Signature: Date:
NEW CONSTRUCTION ACTIVITY OPERATOR:
Name:
Contact:
Mailing Address:
City: State: Zip: Phone:
Email Address (if available):
Indicate if DEQ may transmit general permit correspondence electronically: Yes No
I (We) hereby agree to the change of ownership modification to the referenced General VPDES Permit for Discharges of
Stormwater from Construction Activities (VAR10), and agree to accept all responsibility, coverage, and liability of the
general permit.”
Printed Name: Title:
Signature: Date:
