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					                    VPDES CHANGE OF OWNERSHIP AGREEMENT FORM

        VPDES Permit Number:       VA____________

        Name of Permitted Facility:_______________________________________________________

        Location (City/County):______________________


We, the undersigned, hereby request a transfer of ownership for the referenced permit.
Anticipated date of transfer: _________________________________


CURRENT OWNER: I (We) hereby agree to the transfer of ownership modification to the referenced
VPDES Permit.

Current Owner Name (as listed on the VPDES Permit Cover Page):
        __________________________________________________________________________

*Signed: ____________________________________________ Date: _______________________

Printed Name: _____________________________ Title: _________________________________

Address: _________________________________________________________________________

         _________________________________________________________________________


NEW OWNER: I (We) hereby agree to the change of ownership modification to the referenced VPDES
Permit, and agree to accept all conditions and responsibilities of the permit.

Transferred permit to be issued to: ____________________________________________________

*Signed: ____________________________________________ Date: _______________________

Printed Name: _____________________________ Title: _________________________________

Address: _________________________________________________________________________

         _________________________________________________________________________

Telephone: (_____)__________________

* This form must be signed by properly authorized individuals as specified in the VPDES Permit
Regulation.

				
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Description: Change of ownership