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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 100 North Senate Avenue Indianapolis, Indiana 46204-2251

ADVANCE NOTIFICATION OF TRANSFER OF OWNERSHIP REQUEST FOR NPDES PERMIT
State Form 53919 (1-09) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

INSTRUCTIONS: This form is to be utilized for the notification of a transfer of ownership at least 30 days prior to the proposed transfer of ownership date, per 327 IAC 5-2-6(c) and 327 IAC 5-2-16(e)(4). If notification of the transfer of ownership is received by IDEM 30 days prior to the transfer, no modification fee is required.

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Date Permits Branch Chief Office of Water Quality Indiana Department of Environmental Management 100 North Senate Avenue Indianapolis, IN 46204-2251

Dear Permits Branch Chief,

Please find enclosed the information necessary for NPDES Permit Number IN ____________________ to be transferred from _________________________________________________________________,
(Insert: Legal Name of Current Permit Holder)

to _________________________________________________________________________________.
(Insert: Legal Name of Person to whom Permit will be Transferred)

If you have any questions, please feel free to contact ________________________________________, at ________________________________________. Thank you.

Sincerely, _______________________ _______________________

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NOTIFICATION OF TRANSFER OF NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM PERMIT

Pursuant to 327 Indiana Administrative Code (IAC) 5-2-6(c), the undersigned parties hereby notify the Indiana Department of Environmental Management (IDEM) of their intention to transfer National Pollutant Discharge Elimination System (NPDES) Permit Number IN________________________ from _________________________________________, the
(Insert: Permit Number) (Insert: Legal Name of Current Permit Holder)

"current permittee" and __________________ _________________________________ of the facility,
(Insert: current or previous) (Insert: owner, operator, or owner and operator)

to _____________________________________________________________, the "transferee" and
(Insert: Legal Name of Person to whom Permit will be Transferred)

________________ _____________________________________________ of the facility, effective as
(Insert: current or future) (Insert: owner, operator, or owner and operator)

of ________________________, 20_______.
(Insert: proposed date of permit transfer)

The current permittee acknowledges liability for violations up to the proposed date of permit transfer, and the transferee acknowledges liability for violations on and after the proposed date of permit transfer. The transferee certifies that it is its intention to operate the facility for which NPDES Permit Number IN ___________________ is issued without making such material and substantial
(Insert: Permit Number)

alterations to the facility as would significantly change the nature or quantities of pollutants discharged, and thus constitute cause for permit modification under 327 IAC 5-2-16(d). The undersigned parties understand that the permit transfer will become effective on the proposed date of permit transfer provided that: 1. The information contained in this notification is complete, true, and accurate; 2. This notification is received by IDEM at least thirty(30) days prior to the proposed date of permit transfer; and 3. IDEM does not, within thirty (30) days of receipt of this notification, advise the undersigned parties of its intent to modify, revoke and reissue, or terminate the permit, and to require that a new NPDES permit application be filed, rather than agreeing to the transfer of the NPDES Permit.

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Current Permittee Information and Signature

Please provide the following information regarding the facility for which the NPDES Permit is currently issued: Current Name of the Facility: ________________________________________________________ Current Address of the Facility (number and street, city, state, and ZIP code): ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Current Telephone Number of the Facility: ___________________________________ Please provide the following information regarding the "Current Permittee": Name of the Responsible Official: _______________________________________________________ Title of the Responsible Official: _______________________________________________________ Address of the Responsible Official (number and street, city, state, and ZIP code): ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Telephone Number of the Responsible Official: ______________________________________
Certification Statement I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

____________________________________________________ Signature of Responsible Official

___________________ Date (month, day, year)

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Transferee Information and Signature Please provide the following information regarding the facility for which the NPDES Permit is proposed to be transferred: New Name of the Facility (if different from current name): _____________________________________________________ New Address of the Facility (if different from the current address):
(number and street, city, state, and ZIP code)

_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ New Telephone Number of the Facility (if different from the current telephone number): ________________________________ Please provide the following information regarding the "Transferee": Name of the Responsible Official: _____________________________________________ Title of the Responsible Official: _____________________________________________ Address of the Responsible Official (number and street, city, state, and ZIP code): ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Telephone Number of the Responsible Official: ______________________________________
Certification Statement I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

____________________________________________________ Signature of Responsible Official

___________________ Date (month, day, year)

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