SECTION Vill. CTHER PERMITS
Complete the following table to identify and provide the status of all other permits or approvals necessary to effect the proposed
modification.
—
ooh
Type of Permit/Approvai Date the Application was/will
Required be Submitted Status/Comments
Permit TBD be filed by contractor
m™m 1S
SECTION IX. LEGAL NOTICES
Submit proof of having provided certain legal notifications and filings, as follows:
(1) You must send by certified mail, or deliver in hand, a complete copy of this application to the host municipality, host solid waste
management district and other affected entities, with a “notice of filing,” as specified by Env-Sw 303.
(2) For a type !-A modification, you must send by certified mail, or deliver in hand, a “notice of filing" to each owner of property abutting
the facility site, as specified by Env-Sw 303. If the applicant/permittee or the owner of the facility site owns any abutting parcel of
land, the “notice of filing” must be sent te the owner(s) of the next parcel(s) not owned by the permittee/applicant or facility site
owner.
(3) You must also provide a “notice of filing” to the New Hampshire Department of Justice/Office of the Attorney General (NH
DoJ/AGO) if, pursuant to Section X(2} of this form, you are required to submit business and personal disclosure information.
(4) | You must attach to this application “proof” that notification has been provided as required by (1) through (3) above. Therefore,
attach a copy of the notice(s} of filing and the signature(s) of all required recipients, acknowledging receipt.
SECTION X. CERTIFICATION OF COMPLIANCE/COMPLIANCE REPORT
All applications for permit modification must be submitted with either certification of compliance or a compliance report, as follows:
{ft} Ifyou are ABLE to certify that each of the statements numbered (1) - (8) below are true, do so by your signature.
(2) [F you are UNABLE io certify that each of the statements numbered (1) - (8) below are true, you must.
ty Prepare and submit a separate Compliance Report as specified by Env-Sw 303.15; and
0 lf the proposed modification involves a change in organizational structure, or a change in individuals/entities holding 10% or
more of the permitiee's debt or equity, or a change in officers, directors, partners or key employees, none of which constitutes a
change in operational control of the facility or a change in ownership per Env-Sw 315.02(f, also submit completed "business and
personal disclosure forms" for each non-compliant individual and entity involved in the change. Obtain the required forms from
the P&DRS at (603) 271-2925. Submit the completed forms, with the notice of filing referenced by Section [X(3) of this form and
a copy of the Compliance Report, direct to the New Hampshire Department of Justice/Office of Attorney General, Environmental
Protection Bureau, 33 Capitol Street, Concord, NH 03301-6397. [Note: Copies of the completed disclosure forms should NOT
be attached to this application when it is submitted to DES or to the host municipality, host solid wasie management district and
other effected entities, pursuant to Section LX(1) above. Only the NH DaJ/AGO should receive copies of the disclosure forms].
COMPLIANCE STATEMENT
The applicant shall certify that each of the statements listed in (1}-(8) below are true for each of the following individuals and
entities:
The applicant, and
The facility owner, and
CX] The facility operator, and
All individuals and entities holding 10% or more of the applicant's debt or equify, and
All of the applicant's officers, directors, and partners, and
All individuals and entities having managerial, supervisory or substantial decision making authority and responsibility
for the management of the facility operations or the activity(s) for which approval is being sought.
MIKIMIRIRIR
(1) | No individual or entity listed above has been convicted of or plead guilty or no contest to a felony in any state or federal court during
the 5 years before the date of the application.
(2) | No individual or entily listed above has been convicted of or plead guilty or no contest to a misdemeanor for a violation of
environmental statutes or rules in any state or federal court during the 6 years before the date of the application.
(3) | No individual or entity listed above has owned or operated any hazardous or solid waste facility which has been the subject of an
administrative or judicial enforcement action for a violation of environmental statutes or rules during the 5 years before the date of the
application.
Page 3 of 4 Application Form for Type | Permit Modification Rev, 10/09
