a Na Ohio EPA Permit Coverage Transfer Application Form Division of Surface Water Instructions: Submit the completed form below withthe origina signatures ofthe previous and new owners or those responsible for the permit. Send tothe following address: Ohio EPA, Division of Surface Woter, P.O. Box 1049, Columbus, Ohio 43216-1049. Aleter wil be sent to the transferee and a copy of the letter wil be sent to the transferor ofter the application is reviewed. [A Existing Permit Holder Information (Transferor) -Facittyerme umber: § OOCCOMIB*AL 2. General Permit umber; OH 2 QDDOO- ee en Caen ai T ROW men ices contact _ 5 Division Nam ee ee — ——_ 7. Malling Address After Transfer: [8 Proposed Permit Holder information (Transferee) arent company) Name New TP - STATe Envinenmental Solutions | (330) Ya: 4856 Dickerson Farm Site ‘5. Malling Address forall permit-elated correspondence: 6. Faclty Malling Address (it diferent): 17. Individual authorized to sign applications and Transfer Agreement pursuant to OAC 3745-33-03(F) (principal executive officer, vce president or higher fora corporation; a general partner of a partnership; the proprietor ofa proprietorship; principal executive officer, ranking elected oficial or ‘uly authorized employee of a public entity) [s. Authorization: Pursuant to 40 CFR Part 122.22(b), the individual or position Klentifed in this space i duly authorized by the Individual in Kem 7 to sgn all reports required by permit and other information that may be required by the Director: eaten 9. Operator of Facility Name: Tki- Address State Eavinonmentl Salufons 10. Contact Person for Facility Information or Inspections, name_£,5- Reese hone: G30)11B: 78S 4. Deserbe any material modifications to production or falties, subsequent othe transfer, which may alter the volume or characters of ‘this discharge (including change of SIC code): (Attach additional pages as necessary) There ane yo gtoteasil Moddastore to production of facil tres, pubseguent Leth, tearsler, whith may alle the yllame ot ehassctersshes of thes di se haeye. wna Page tof?'2s the holder of an NPDES permit which stipulates esponsibility, coverage and liability for operations involving discharges of wastewater from the facility located at ys hereby applies for approval ofthe Director to transfer the permit I a en ee fee sees to continue to assume the responsiblity for compliance Tatoo with all terms; imitations and conditions and any coverage or lability thereunder for a period ending on a L Sn 2s the proposed new permittee, hereby my ‘rouse! ‘agrees to assume the responsibility for compliance with the entirety of the coverage, responsibilty and liability of the NPDES permit commencing at oa In witness whereof, the partes have executed this Agreement on sitisso agreed “ransteror: Transferee: . . femoris — UTTAR Envipoames cael Sensor Thl- State. Envesamente ( Sdlehirne BY: company stn Stee _ mrcape ite: Tile: 12, By signing this form, | (transferee), certify and acknowledge that | have read and fully understood terms and conditions of General Permit [Number: OH | certify under penalty of law that the information submitted is true, accurate and complete. | am aware that there are significant penalties for submitting fase information, including the possibilty of fine and imprisonment for knowing violations. [Transferee Signature: ite: Date: ona Page2ot2; Notice of Termination (Not) of Coverage Under Ohio 2 ChioEPA Environmental Protection Agency General NPDES Permit Division of Surface Water {Read accompanying istton careful before completing this form) submission ofthis NOT constutes notice thatthe party dented in Section I af ths form longer outhored te escharge into state waters under the NPDES ener permit program. NOE: Al necessary formation mustbe provided oa this form Do nt use oreo ul on this form. Forms warsmited by fx il ot be accepted. Thereof sociated with submiting this form. |. Permit information: NPDES General Permit Mimber: 0H COODOO 4 Fatty General Permit Number: ae ¥Ab ‘Ouner/ Applicant nfrmation/Maling Adress company (pplent Name: Li aes Mating (Apeant) Ades: ty: State: Ohio pose: contat Peron: Prone: cis contact mat eas |. Faality/Sit oeaton Information Fality Name: ickerson Laem Site Faclty Contact Person: Phone: () Foxe V Faclty Contact Email: : IV. Reason for Termination Hransferof Ownership C] Cease to Discharge L] FaaityGosed [] Project Completed (Obtained tndhdual Permit CI] V.Cerfeations| Standard Certfiston: cenfy under pena of nw toa dachorges ators by he NPDES genera permit hoe bee sininted tht am no longer the operat of hefty. understand tht by subniting th NOT, am no longer auton to cichorge under ths ener permit on at charging Poon to woes ofthe state wiht on NPDES permit unl ander ORC 611 Name (typo: Th signature: ate: Induttl Storm Water and Goal Mining Activity Cotati Only: scr under pena of ow ta ol charges ossocked with eid ot to oaths the above eferencedNPOES gener permit hv been ehminate, ta! am No anger te operator the factor he caso coal mine tht the SCRA band ha een esse by ODN sono eclamatin wnsetand tat by submitting ts NO, no longer outed to dicharge storm water steceted wth int acti unde the gna gem ond thot dechrgn polars stom ote eso with aot wotes ofthe state anol unde ORC 611 wher the dihage isnt authored by an MPDES per. Name typed): The signature ate: storm Wator Construction Activity Certfeatlon Only For nonsesidentia deeiopment, Icey under pena ofl that por tthe submit fh NOT, elements of he starm wate potson revertin plan have ben complete, the curd sc oe ented foci hove een tbed and tamporry ereon ond semen conta mesures have bet femved et the prorat neo arm water dsehorges asic wit conscneivy fromthe rfid ft that re autre bythe aoe referenced NPDES grea perm hove ters be elite, rer restentl developments ny, ety nde pena ofa thet, rir othe submit of ts NO. eh emporay stebzaton hes een camped andthe whch nudes home, Ios been tronsferedo the homeowner fi final tbr hos hen cmpeed an the et which does rt nee hme Ps bee Wonered oe property ower oil no stanton nos teen implemented ont, whch es ome, ond he as een Vonsfrred the hamcowne: andestond et, by sarin hs NOT, am nooner uthorsedte dachorg storm mate oxo wth constriction tty bythe general er, nd that charging polutnt Storm wteresocoted with constuction iy to waters ofthe tate nll under ORC 61 re he dacharge sot cutarsed yon NPDES peri Name (typed: Tie Stature: EPA 4493 (ev. 6/16) Page tof"48.34" DICKERSON FARM SITE BELMONT COUNTY, OHIO N 2s So gs ne i : ENVIRONMENTAL SERVICES