HomeMy WebLinkAboutWPO201500087 Permit 2016-02-11Transfer 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: VAK I OCA) 0d
Construction Activity Name: a, I I V &Vacp
CURRENT CONSTRUCTION ACTIVITY OPERATOR:
Date of Transfer (mm/dd/yyyy):
Name: Ck.,VA CA> n4yw LLo � (i [
Contact: a ft"j i -e- 14,E "T
Mailing Address:— , IqS
City: I mff(oAkSIf, State: i/� Zip: Phone: ki 1 -� 7� o ! /
Email Address (if available):_ Ca e17 i- IV 5 . fa
"I (We) hereby agree to the transfer of ownership modification to the referenced General VPDES Permit for Discharges of
Stormwater from Construction Activities (VAR10)." ` l
�_ V
Printed Name: C ��+' ��� A '�° ` 1 Title: f
Signature:_ Date:
NEW CONSTRUCTION ACTIVITY OPERATOR: 05(� � Cif t(y
Name: L o Lin ro,&K ~ate' 5, L-i
Contact: �tf 1i1 �+? de:I!
I
Mailing Address:[ _[ ± T7 U 1 1 pinl
City: t WA -Its' s V State: VA _ Zip: Of.. Phone:'4D 6, - 7-7 0 �,...
Email Address (if available): KUfu f a �i
Indicate if DEQ may transmit general permit correspondence electronically: Yes 0 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), nd a r e to accept all responsibility, coverage, and liability of the
general permit." _ ��_
Printed Name: t t �� ; r ? 1l. �. Title:
Signature:
9 ti Date:
01 /2014
Page 1 of 1