APPLICATION FOR OPERATOR - WV Department of 操作员WV部门应用.doc

APPLICATION FOR OPERATOR ASSIGNMENT OR REASSIGNMENT1. A permittee/owner who wishes to assign or reassign the operation of the solid waste facility through an agreement, contract, or other legal instrument, to another party but retain the permit must request and receive prior written approval utilizing forms prescribed by the Secretary. Please attach a completed copy of the proposed operators background investigation disclosure statement(s) as required under subsection 3.14 of this rule. The proposed operator may receive this form by request to the WVDEP. This application will not be issued until the proposed operator has successfully completed the background investigation.2. Current Permittee/Owner information: Name:_Address:_Telephone Number: _ 3. Permit Information:Permit Number: _ Date of expiration: _Location: County _District _Nearest Post Office _(City)4. If the permittee is applying to reassign the operation of the facility to another operator, please complete the following for the proposed operator: Name:_Address:_Telephone Number: _ (Please attach copies of the legal instruments that has, or will, terminate the permittees agreement or contract with the current operator.) 5. If the permittee is applying to assign the operation of the facility to an operator for the first time, please complete the following for the proposed operator: Name:_Address:_Telephone Number: _ (Please attach copies of the enabling legal instruments such as the permittees agreement or contract with the proposed operator.) - 2 -Owner/Permittee Signature I, , having been duly sworn depose and attest that all of the representations contained in the foregoing application are true to the best of my knowledge; that I am the principal executive officer of the owner and permittee and that this application is being executed by the persons required by law. I further understand this application assigns or reassigns the solid waste facility operating rights only. Signed _Taken, subscribed and sworn to before me the undersigned authority in my said county, this _ day of _, 20_. Notary Public _ My Commission Expires _ State of:_ County of:_ Proposed Operator Signature I, _, having been duly sworn depose and attest that I am the principal executive officer of the operator and that this application is being executed with my consent. All of the representations contained in the foregoing application are true to the best of my knowledge; and that this application has been executed by the persons required by law. Signed _Taken, subscribed and sworn to before me the undersigned authority in my said county, this _ day of _, 20_. Notary Public _ My Commission Expires _ State of:_ County of:_We will process your personal information (email address, mailing address and/or telephone number) in accordance with the State of West Virginias Privacy Policy for appropriate and customary business purposes. Your personal information may be disclosed to other State agencies or third parties in the normal course of business or as needed to comply with statutory or regulatory requirements, including Freedom of Information Act requests. The Division of Water and Waste Management will appropriately secure yo