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DocuSign Envelope ID:986HB350-041 E-4B91-A91A-D8114535CA35
<br /> NAME CHANGE AND/OR TRANSFER INSTRUCTIONS
<br /> A. ACTION TO BE PERFORMED
<br /> Check the appropriate box to indicate a name change and/or permit transfer.
<br /> • For a name change,provide the effective or scheduled date of the name change.Please note that for name changes,DEQ prefers to
<br /> process your request after the name has been legally changed to avoid incorrectly modifying its files should the change not occur.
<br /> • To transfer a permit to a new owner,provide the date on which you want the transfer to occur.Transfer will not occur until DEQ has
<br /> received the appropriate signatures and fee and reviewed the transfer information.Approval of a transfer may take up to 30 days to
<br /> process.
<br /> B. PREVIOUS INFORMATION
<br /> 1. Enter the previous legal name and common name of this facility or operation if different than the legal name.
<br /> 2. Enter the facility's physical address(physical location,not mailing address),including city, state,and zip code.
<br /> 3. Enter the DEQ permit number and facility file number(also known as the site ID number;this number may be found on the first page
<br /> of your permit).
<br /> C. NEW INFORMATION
<br /> 1. Enter the new legal name.This name will appear on the permit and must be the legal Oregon name(for example,Acme Products,Inc.)
<br /> or the legal representative of the company if the company operates under an assumed business name(for example,John Smith,dba
<br /> Acme Products).The name must be a legal,active name registered with the Secretary of State-Corporation Division unless otherwise
<br /> exempt by regulation(503-986-2200 or http://sos.oregon.gov/business/Pages/register.aspx).
<br /> 2. Enter the new common name of this facility or operation if different than the legal name.
<br /> 3. Enter the name,telephone number,and e-mail and mailing addresses of the Responsible Official.The Responsible Official is the
<br /> person that receives official correspondence from DEQ,such as renewal notices or notices of noncompliance,and may be contacted if
<br /> there are questions about this application.
<br /> 4. Enter the name,telephone number,and e-mail and mailing addresses of the Facility Contact if different from the Responsible Official.
<br /> The Facility Contact is the person located at the facility that has specific knowledge of the facility or operation under permit(for
<br /> example,the treatment plant operator),and may be contacted if there are specific questions about this application.
<br /> 5. Enter invoicing information for billing purposes if different from new legal name(for example, "Invoice To:Business Office").
<br /> 6. Complete as indicated.Attach an explanation if changes are being made to the discharge regulated by the current permit.
<br /> D. SIGNATURE REQUIRED FOR NAME CHANGE
<br /> The signature of a legally authorized representative must be obtained before DEQ will change the name of a permittee.
<br /> E. SIGNATURES REQUIRED FOR PERMIT TRANSFER
<br /> The signatures of legally authorized representatives from the previous owner and new owner must be obtained before DEQ will transfer
<br /> a permit If the previous owner is not available,DEQ will accept a bill of sale or other proof that the new owner has acquired a property;
<br /> interest in the permitted activity;,
<br /> Definition of Legally Authorized^Representative
<br /> Please also Provide-the-Information requested in brackets[] For NPDES permits,see 40 GFR§ 122 22 for more detail.
<br /> • Corporation—President,secretary,treasurer,vice-president,or any person who performs principal business functions;or a
<br /> manager of one or more facilities employing more than 250 persons or having gross annual sales or expenditures exceeding$25
<br /> million that is authorized in accordance to corporate procedure to sign such documents
<br /> • Partnership—General partner[list of general partners, their addresses and telephone numbers]
<br /> • Sole Proprietorship—Owner(s)[each owner must sign the application]
<br /> • City,County, State,Federal,or other Public Facility—Principal executive officer or ranking elected official
<br /> • Limited Liability Company—Member[articles of organization]
<br /> • Trusts—Acting trustee[list of trustees, their addresses and telephone numbers]
<br /> FEE AND APPLICATION SUBMITTAL
<br /> Please see the cover letter enclosed with this application form or call the appropriate regional office below for fee information and to
<br /> determine where to send this application. Send this form and fee to the regional office. Please reference the current fee table to
<br /> determine the appropriate fees for your permit.Make your check payable to the Department of Environmental Quality.
<br /> DEQ,Northwest Region �' DEQ Western Region l)EQ Eastern Region'
<br /> 700 Lloyd Building at Onsite Sewage Stormwater All Other Permits 800 SE Emigrant,#330
<br /> 700 NE Multnomah St., Benton, Lane, 165 E 7`h Ave,#100 165 E 7`h Ave,#100 4026 Fairview Pendleton,OR 97801
<br /> Suite#600 Lincoln,Linn, Eugene,OR 97401 Eugene,OR 97401 Industrial Dr SE 541-276-4063 or
<br /> Portland,OR 97232 Marion, Poly 541-686-7838 or 541-686-7838 or Salem,OR 97302 1-800-452-4011
<br /> 503-229-5263 or Yamhill 1-800-844-8467 1-800-844-8467 503-378-8240 or
<br /> Coos, Cu 381 N 2nd St 1-800-379-7677 Crook,Deschutes,
<br /> 1-800-452-4011 "y Benton, Coos, Gilliam, Grant,
<br /> Douglas(coast) Coos Bay,OR 97420 Curry,Douglas, Benton, Coos, Curry, Harney,Jefferson,
<br /> 541-269-2721
<br /> Clackamas, Clatsop, Jackson,Josephine, Douglas,Jackson, Klamath,Lake,
<br /> Columbia,Multnomah, Douglas(east) 221 Stewart Ave,#201 Lane,Lincoln,Linn, Josephine,Lane, Malheur,Morrow,
<br /> Tillamook, Washington Jackson, Medford, OR 97501 Marion, Polk, Lincoln,Linn,Marion, Wallowa, Umatilla,
<br /> Josephine 541-776-6010 or . Yamhill Polk, Yamhill Union, Wasco, Wheeler
<br /> 1-877-823-3216
<br /> -2- last updated:Oct 10,2017(MRB)
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