This Application must be certified by the Responsible Person (Transferor) or an agent for the Responsible Person as authorized through an MDE e-Permits subscriber agreement submitted to MDE and accepted by MDE for use in this system.

I acknowledge this transfer of authorization under the terms of the permit. I understand that I, the original permittee, must maintain the records in Part IV.C.4 of the permit that document the permit activity up to the date of transfer, and that I must maintain those records for three (3) years from the date of transfer. Both the original permittee and the new permittee must maintain a copy of the Transfer of Authorization document.

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.

Specify who you are.