Fillable New York environment conservation Application For Permit Transfer

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New York environment conservation Application For Permit Transfer

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PART 1 - TRANSFEREE (New Owner/Operator/Lessee/Applicant) Completes:
1. List Permit Number(s) And Their Effective And Expiration Dates: List Pending Application Number(s):
2. Name Of Transferee: Telephone Number (Daytime): Transferee is a/an: (check all that apply)
( ) Owner Operator
Mailing Address: Email: Lessee Applicant
If other than an individual, provide
Post Office City, State, Zip Code: Taxpayer ID Number:
3. Name Of Facility/Project:
Location (or Street Address, P.O. City, State, Zip Code, if applicable):
Town / Village / City: County:
4. Facility Contact Name: Telephone Number (Daytime):
( )
Mailing Address: Email:
Post Office City, State, Zip Code:
5. Has Work Begun On The Project?
Yes No If “No,” proposed starting date: ___________________________ Approximate completion date:_________________________
If there will be any modifications to the current or proposed operation or construction, the transferee must attach a statement specifying
the details.
6. CERTIFICATION: This certifies that the Transferee seeks to be the legally responsible party for operations or project development either
authorized by the permits identified above or proposed in applications identified above. The Transferee has a copy of the permit(s) and/or
application(s) and understands and will comply with all conditions in the referenced permit(s) and supports the content of referenced application(s).
Facility operations/project scope/discharges/emissions will remain the same as authorized or as proposed in pending applications. Further, I
hereby affirm that under penalty of perjury that information provided on this form and all attachments submitted herewith is true to the best of my
knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
Printed Name and Title of Transferee _________________________________________________________________________________________
Signature of Transferee _______________________________________________________________________ Date________________________
PART 2 - TRANSFEROR (Present or Former Owner/Operator/Lessee/Applicant) Completes:
1. Name Of Transferor: Telephone Number (Daytime): If other than an individual, provide
( ) Taxpayer ID Number:
Mailing Address: Email:
Post Office City, State, Zip Code:
2. Name Of Facility/Project, if different from Facility Name in Part 1:
3. CERTIFICATION: This certifies that ownership, operation, or a lease for the facility identified in Part 1 of this form will be / was conveyed to
the party identified as the Transferee on _____________________________ (date). I affirm that this conveyance includes the rights and
obligations of the permits, approvals, or applications identified above.
Printed Name and Title of Transferor _________________________________________________________________________________________
Signature of Transferor ________________________________________________________________________ Date_______________________
PART 3 - PERMIT TRANSFER VALIDATION SECTION - Department Of Environmental Conservation Completes:
FOR DEC USE ONLY
Transfer of permit approved, effective as of ___________________. Transferee subject to conditions of original permit, without exception.
Transfer of permit approved, with the following modifications or contingencies related to this Permit Transfer:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
See attached revised permit page(s): _________________________________________________________________________________
Transfer of application approved. See attached for additional information required.
Transfer denied, new application required. Please complete the enclosed permit application and return it to the undersigned Regional Permit
Administrator at the address listed on the reverse side of this form.
__________________________________________ ___________________________________________________ __________________
NYSDEC PERMIT ADMINISTRATOR SIGNATURE DATE
copies to:
FOR DEC USE ONLY
Application For Permit Transfer
and Application for Transfer of Pending Application
NOTE: Please read ALL instructions before completing
this application. Please TYPE or PRINT clearly in ink.
(rev. 8/16)
RESET
Application for Permit Transfer and Application for Transfer of Pending Application
General Instructions
This form is to be used for transferring valid permits and pending applications for permit from a present permit holder or applicant (Transferor) to
another party taking responsibility as a permittee or applicant (Transferee).
Legally Responsible Party means a permittee lawfully accountable for undertaking a permitted action in accordance with the provisions and
conditions of a permit, or an applicant lawfully accountable for the content of an application.
The Transferee (New Owner/Operator/Lessee/Applicant) must:
1. Complete Part 1 of this application form.
2. Have Part 2 of this applicant form completed by the Transferor (former Owner/Operator/Lessee/Applicant). If the information requested in
Part 2 cannot be obtained, the Transferee must attach a statement giving the reason(s).
3.
Submit completed application form to the Regional Permit Administrator, Division of Environmental Permits, at the appropriate office of the
department (see map below).
Other Instructions
4. Applications by a Corporation shall be signed by a member of the board of directors or a “high managerial agent” of the corporation as that
term is defined in the § 20.20 of the Penal Law; a Partnership by a general partner; a Sole Proprietorship by the proprietor; a Municipality or
Public Corporation by the duly authorized principal executive officer; and a State Agency by a person duly designated by the commissioner
or other agency head. Applications by a Limited Liability Company shall be signed by a member or manager in accordance with the LLC’s
articles of organization as filed with the Secretary of State.
5. If other than the owner makes application, written consent of the owner to use the property/facility must accompany the application.
6. The Transferee is responsible for obtaining any other required federal, state or local permits.
7. The department may request additional information in accordance with the Record of Compliance Enforcement Guidance Memorandum, or
with regard to financial assurance guaranties.
8. If available, attach a copy of the first page of the permit(s) requested for transfer.
Contact the Regional Permit Administrator, Division of Environmental Permits, at the appropriate office of the department, as given below, for
assistance regarding any of the above requirements.
NYS Department of Environmental Conservation
www.dec.ny.gov
NYS DEC REGION 4 Sub-Office
Regional Permit Administrator
65561 State Highway 10
Stamford, NY 12167-9503
607-652-7741 fax: 607-652-2342
email: DEP.R4@dec.ny.gov
< For Delaware and Otsego Counties
NYS DEC REGION 5
Regional Permit Administrator
PO Box 296
1115 NYS Route 86
Ray Brook, NY 12977-0296
518-897-1234 fax: 518-897-1394
email: DEP.R5@dec.ny.gov
NYS DEC REGION 5 Sub-Office
Regional Permit Administrator
232 Golf Course Rd
Warrensburg, NY 12885-1172
518-623-1282 fax:518-623-3603
email: DEP.R5@dec.ny.gov < For
Fulton, Saratoga, Warren, and
Washington, Counties
NYS DEC REGION 6
Regional Permit Administrator
Dulles State Office Building
317 Washington Street
Watertown, NY 13601-3787
315-785-2245 fax: 315-785-2242
email: DEP.R6@dec.ny.gov
NYS DEC REGION 6 Sub-Office
Regional Permit Administrator
Utica State Office Building
207 Genesee Street, Room 1404
Utica, NY 13501-2885
315-793-2555 fax: 315-793-2748
email: DEP.R6@dec.ny.gov
< For Herkimer, and Oneida Counties
NYS DEC REGION 7
Regional Permit Administrator
615 Erie Blvd West, Room 206
Syracuse, NY 13204-2400
315-426-7438 fax: 315-426-7425
email: DEP.R7@dec.ny.gov
NYS DEC REGION 7 Sub-Office
Regional Permit Administrator
1285 Fisher Avenue
Cortland, NY 13045-1090
607-753-3095 ext. 233
fax: 607-753-8532
email: DEP.R7@dec.ny.gov
< For Broome, Chenango, C
ortland,
Madison, Tioga and Tompkins
Counties
NYS DEC REGION 8
Regional Permit Administrator
6274 East Avon - Lima Road
Avon, NY 14414-9519
585-226-5400 fax: 585-226-2830
email: DEP.R8@dec.ny.gov
NYS DEC REGION 9
Regional Permit Administrator
270 Michigan Avenue
Buffalo, NY 14203-2915
716-851-7165 fax: 716-851-7168
email: DEP.R9@dec.ny.gov
NYS DEC REGION 9 Sub-Office
Regional Permit Administrator
182 East Union, Suite 3
Allegany, NY 14706-1328
716-372-0645 fax: 716-372-2113
email: DEP.R9@dec.ny.gov
< For Allegany,
Cattaraugus, and
Chautauqua Counties
NYS DEC REGION 1
Regional Permit Administrator
SUNY @ Stony Brook
50 Circle Road
Stony Brook, NY 11790-3409
631-444-0365 fax: 631-444-0360
email: DEP.R1@dec.ny.gov
NYS DEC REGION 2
Regional Permit Administrator
1 Hunter's Point Plaza
47-40 21st Street
Long Island City, N
Y 11101-5407
718-482-4997 fax: 718-482-4975
email: DEP.R2@dec.ny.gov
NYS DEC REGION 3
Regional Permit Administrator
21 South Putt Corners Road
New
Paltz, NY 12561-1620
845-256-3054 fax: 845-255-4659
email: DEP.R3@dec.ny.gov
NYS DEC REGION 4
Regional Permit Administrator
1130 North Westcott Road
Schenectady, NY
12306-2014
518-357-2069 fax: 518-357-2460
email: DEP.R4@dec.ny.gov
<
Counties/Areas served by the DEC
Regional Sub-Office are listed
below their contact information.
For all other Counties/Areas,
contact the DEC Regional Office.
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New York environment conservation Application For Permit Transfer

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Completed 7 March 2020

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