State of New Hampshire s9

State of New Hampshire

WATER DIVISION WASTEWATER ENGINEERING BUREAU P.O. BOX 95 29 HAZEN DRIVE CONCORD, NH 03302-0095

(603) 271-3908

SEPTAGE PERMIT MODIFICATION APPLICATION Pursuant to: Env-Wq 1603.12 - Septage Management Rule

1. Permit Holder Information: Name: Address : Zip Home Phone #: ( ) Permit #:

2. Owner Information: Name: Address: Phone #: ( ) Zip

3. Site/Facility Information: Name: Address: Phone #: ( ) Zip

4. Current or Proposed Operator(s): (attach separate sheet if needed) Name: Address: Zip Business Phone #( ) Home Phone #: ( )

5. Current or Proposed Hauler(s): (attach separate sheet if needed) Name: Address: Zip Business Phone #( ) Home Phone #: ( )

6. Detailed description of all proposed modifications: (attach separate sheet if needed)

Septage Permit Modification Application Page 2 of 3

7. If applicable, a revised site plan or facility plan prepared in accordance with Env- Wq 1608.07, Env-Wq 1609.07 or Env-Wq 1611.08 as applicable.

8. If applicable, a revised management plan prepared in accordance with Env-Wq 1608.08, Env-Wq 1609.08 or Env-Wq 1611.09.

9. If applicable, revised facility plans and specifications for construction and closure stamped by a New Hampshire registered professional engineer.

10. An explanation of why the proposed modification(s) is necessary or desirable: (attach separate sheet if needed)

11. The effect of the proposed modification(s) on the site or facility’s capacity and life expectancy: (attach separate sheet if needed)

12. The identification and status of all other federal or state permits or approvals necessary to effect the proposed modification(s): (attach separate sheet if needed)

13. The permit holder’s proposed scheduled for implementing the proposed modification(s): (attach separate sheet if needed)

14. A list and status of any outstanding violations, accompanied by a statement from the permit holder indicating how full compliance shall be attained prior to approval of the modification: (attach separate sheet if needed)

02/07 Septage Permit Modification Application Page 3 of 3

15. A list of any current abutters affected to whom the notice was not provided at the time of the original application: (attach separate sheet if needed)

16. Each application must be accompanied by the fee specified in Env-Wq 1608.05, Env-Wq 1609.05 or Env-Wq 1611.06, as applicable.

17. Applicant Signature:

The applicant(s) must sign the following statement prior to submitting this application. All copies of the application filed with DES must bear the applicant’s ORIGINAL signature(s). If the applicant is not an individual, the application shall be signed by an individual duly authorized by the applicant.

 To the best of my knowledge and belief, the information and material submitted herewith is correct and complete.

 I understand that any approval granted by DES based on false and/or incomplete information shall be subject to revocation or suspension, and that administrative, civil or criminal penalties may also apply.

 I certify that this application is submitted in a complete and accurate form as provided by DES without alteration of the text.

Applicant Name (Print Clearly or Type) Co-Applicant Name (Print Clearly or Type)

Applicant Signature Co-Applicant Signature

Date Date

SUBMIT TWO COPIES OF ALL INFORMATION TO:

Residuals Management Section Wastewater Engineering Bureau NH Department of Environmental Services P.O. Box 95 Concord, NH 03302-0095