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Application for transfer of ownership for all permit,certifications and authorizations PART 1 pg 3 <br /> 5. BILLING CONTACT if different than permittee <br /> Responsible Position (title) <br /> Held by (person) <br /> Telephone# email address <br /> Organization <br /> Mailing address <br /> City State Zip <br /> 6. OTHER CONTACT TYPES (check below) Add pages if necessary. <br /> Responsible Position (title) <br /> Held by (person) <br /> Telephone# email address <br /> Organization <br /> Mailing address <br /> City State Zip <br /> Pretreatment CoordinatorCompliance Contact <br /> _ <br /> Environmental Contact Stormwater MS4 Responsible Party <br /> — <br /> — <br /> Biosolids Responsible Party ❑ Stormwater Authorized Representative <br /> -Inspection Facility Contact Property Owner <br /> -Consultant Ot ier <br /> REQUIRED CERTIFICATION SIGNATURE [Reg 61.4(1)(h)] <br /> Signature of Applicant: The applicant must be either the owner and/or operator of site. The applica- <br /> tion must be signed by the applicant to be considered complete. In all cases, it shall be signed as <br /> follows: <br /> a) In the case of corporations, by a principal executive officer of at least the level of viceopresident or his <br /> or her duly authorized representative, if such representative is responsible for the overall operation of <br /> the facility from which the discharge described in the application originates. <br /> b In the case of a partnership, by a general partner. <br /> c) In the case of a sole propnetorship, by the proprietor. <br /> d In the case of a municipal, state, or other public facility, by either a principal executive officer, ranking <br /> elected official, or other duly authorized employee if such representative is responsible for the overall <br /> operation of the facility from which the discharge described in the form originates. <br /> I certify under penalty of law that I have personally examined and am familiar with the information submit- <br /> ted herein, and based on my inquiry of those individuals immediately responsible for obtaining the infor- <br /> mation, I believe that the information is true, accurate, and complete. Ipam aware that there are signifi- <br /> cant penalties for submitting false inform ion, i cludi g the possibility of fine and imprisonment. <br /> Signature(Legally Responsible Party) Date 5/1/2024 <br /> Name (printed) Michael Cunningham Title Division Director <br />