MDE e-Permits

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Permit Number: 13CH0023

Transfer of Authorization

This Transfer of Authorization form is to be completed by a permittee who holds an Individual or General Permit for Stormwater Associated with Construction Activity, in accordance with the Environmental Protection Agency’s National Pollutant Discharge Elimination System stormwater program, if the permittee intends that another person assume control of permitted activities on the site or if the site’s ownership changes. In this event, the permittee (the "transferor") must familiarize the person who is assuming control of the permitted activities (the "transferee") with the permit and provide the transferee with a copy of the Permit. The transferor and transferee must both certify this Transfer of Authorization. The transfer shall become effective after MDE reviews and accepts a completed Transfer of Authorization, certified by both the transferor and transferee. Both parties will receive an email notification of the transfer.

Transferee Information

Provide the name of the person to whom this permit is being transferred (Transferee). This person will be required to certify this application as the Transferee.

Professional Title:

Specify:

First Name:

Last Name:

Organization: (if applicable)

Provide the street address of the Transferee. This could be the address of the organization (NOT the site/project).

Street:

Street 2: (optional)

City:

State:

ZIP Code:

Check box if the mailing address of the Transferee is different from above.

Street/P.O.Box:

Street 2: (optional)

City:

State:

ZIP Code:

Provide contact information for the Transferee.

Phone:

Email:

Re-Type Email:

Contact Person

Provide contact information for the person associated with this permit. This may be different from the reponsible person named above.

Professional Title:

Specify:

First Name:

Last Name:

Phone:

Email:

Facility Ownership

Indicate the ownership of the facility.

Ownership:

Federal Tax ID Number:

Resident Agent for Corporation
A resident agent is a person or entity that serves as the point of contact for a business organization, for the purpose of receiving legal notices from the state, addressed to the business. Enter resident agent information below.

Specify:

First Name:

Last Name:

Street:

City:

State:

ZIP Code:

Workers Compensation Coverage

Proof of workers’ compensation coverage is required under § 1-202 of the Environment Article. Applicants must provide either worker’s compensation coverage information or a Certificate of Compliance. State and Federal agencies have coverage and do not need to provide this information.

Will you be attaching a Certificate if Compliance with this application?

Yes

Upload this document below. Click ‘Choose File’ to browse documents, then ‘Add File for Upload’. Then click ‘Continue’.

The following file formats are accepted: JPG, TIF, PDF, DOC, DOCX.

File Name
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Provide your provider name, and the Insurance Policy or Binder Number.

Name of Provider:

Policy/Binder Number:

MDE e-Permits

Permit Number: 13CH0023

Transfer of Authorization

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