(4) | No individual or entity listed above has been the subject of any administrative or judicial enforcement action for a violation of
environmental statutes and rules during the 5 years before the date of the application;
(5) | All hazardous and solid waste facilities owned or operated in New Hampshire by any individual or entity listed above are in
compliance with either.
(a) | All applicable environmental statutes, rules, and DES permit requirements; or
(b) | A DES approved schedule for achieving compliance therewith.
(6) | All individuals and entities listed above are in compliance with all civil and criminal penalty provisions of any outstanding consent
agreement, settlement, or court order to which DES is a party.
(7) | All individuals and entities listed above have paid, or are in compliance with the payment schedule for any administrative fine
assessed by DES.
(8) | All individuals and entities listed above are in compliance with all terms and conditions under every administrative order, court order
or settlement agreement relating to programs implemented by DES.
Signature of the permittee/applicant certifying the above statements are true:
Permittee/Applicant Name (Print Clearly or Type) Kimco Webster Square, LLC
wn, Authorized Agent
= e, Nicholas Bro
Permittee/Applicant Signature Zot —
Date tef/u4/i?
SECTION XI. PERMITTEE/APPLICANT SIGNATURE REQUIREMENTS
The permittee/applicant must sign the following statement prior to submitting this application. All copies of the application filed
with DES must bear the permittee’s/applicant’s ORIGINAL signature. If the permittee/applicant is not an individual, an individual
duly authorized by the permittee/applicant shall sign the application.
To the best of my knowledge and belief, the information and material submitted herewith is correct and complete. | understand that any
approval granted by DES based on false and/or incomplete information shall be subject to revocation or suspension, and that
administrative, civil or criminal penalties may also apply. | certify that this application is submitted on a complete and accurate form, as
provided by DES, without alteration of the text.
Permittee/Applicant Name (Print Clearly or Type) Kimco Webster Square, LLC
Nicholas Brown, Authorized Agent
Permittee/Applicant Signature ee ee
Date pel fre
SECTION Xll. PROPERTY OWNER SIGNATURE
If the permittee and property owner are not the same, the property owner must also sign this form as follows. All copies of the
application filed with DES must bear the property owner’s ORIGINAL signature. If the property owner is not an individual, an
individual duly authorized by the property owner shall sign the application.
(1) | | hereby affirm that the permittee/applicant has the legal right to occupy and use the property on which the subject facility is or will be
located for the purposes specified in this application.
(2) | | hereby affirm that | shall grant access to the property for closure and post-closure monitoring of the subject facility and site as
required by RSA 149-M and the New Hampshire Solid Waste Rules (Env-Sw 100 - 300 and Env-Sw 400 - 2000), as amended.
Property Owner Name (Print Clearly or Type) Kimco Webster Square, LLC
Nicholas-Brown, Authorized Agent
Property Owner Signature
Date ped4/i?
Page 4 of 4 Application Form for Type | Permit Modification Rev. 10/09
