Louisiana department of environmental quality




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LOUISIANA DEPARTMENT OF ENVIRONMENTAL QUALITY

Addendum to Permit Applications per LAC 33:I.1701




Introduction

This Addendum to Permit Applications provides information to the Permits Division which is used to comply with the requirements of LAC 33:I.1701 – Requirements for Obtaining a Permit. Authority to ask for this information is contained in the Louisiana Administrative Code, Title 33. Copies of this law are available from the Regulation Development Section of the Office of Environmental Assessment, or on the Internet at:



http://www.ldeq.org/planning/regs/title33/index.htm
Who Should Submit an Addendum to Permit Applications?

The Addendum to Permit Applications should be submitted for any permit application submitted for a new source and for all permit actions, including renewals and changes of ownership. Air permit modification requests are exempt from this requirement unless they include, or are limited to, a change of ownership.


What If I Previously Sent an Addendum to Permit Applications to DEQ?

You must submit this addendum with each permit application, as stated above. It is acceptable to submit a copy of a previously submitted form, if the original signature date is not more than twelve months old. Indicate the original submittal date and the permit number for which it was previously submitted. Please review the information to ensure that it is still correct.


What You Should Submit and What You Should Keep

Route the original and two photocopies to this agency. For Part 70 Air Permit applications, a copy should be submitted directly to EPA's Dallas office -- EPA Region 6 (6PD-R), 1445 Ross Avenue, Suite. 1200, Dallas TX 75202-2733.


Acceptable Answers

“NA” is not an acceptable answer. If a particular section does not apply to you, explain why. Please attach additional sheets for the required information. The Department may require the submission of additional information if it deems such information necessary.


General

Do not write information in the top or left side margin of this form as file folder bindings may cover the information.




Step-by-Step Instructions

1 Media Type

Indicate whether this is for a Solid Waste, Air, Water, Hazardous Waste or Radiation Licensing application.


2 Agency Interest Number

If blank, type or print the Agency Interest Number in the space provided at the top of each page (if known); otherwise, leave blank.



3 Indicate if Copy of Previously Submitted Form

Indicate whether or not this is a copy of a previously submitted form. If yes, indicate the original submittal date and the permit number for which it was previously submitted. You may not submit a copy which has an original signature date that is more than twelve months old.


4 Company Name, Parent Company, Plant Name and Location

If blank, type or print the name of the company, the name of its parent, the name of the plant, if any, the parish where the plant is located, and the closest town in the same parish as the facility. Check the appropriate box to indicate if the permittee is the owner or operator of the facility.


5 List of States With Similar Actions

Please provide a list of the states where you, as applicant, have federal or state environmental permits identical to, or of a similar nature to, the permit for which you are applying.


6 Outstanding Fees

Do you owe any outstanding fees or final penalties to the Department? If so, please explain.


7 Registration with Secretary of State

If your company is a corporation or a limited liability company, please provide proof of registration with the Secretary of State.


8 Responsible Official

Enter the name, address, and phone number of the responsible company official. Part 70 sources must meet the requirements of LAC 33.III.502 regarding the Responsible Official.


9 Certification by Responsible Official

An authorized company agent should sign and date the form confirming its accuracy and completeness.





Media Type (check one)







Agency Interest Number:      

Hazardous Waste



Air 




Is this a copy of a previously submitted form? Yes  No 

Solid Waste



Water 




If yes, indicate the original submittal date:      

Radiation Licensing









If yes, indicate the original permit number:      



Department of Environmental Quality

Permits Division

P.O. Box 4312

Baton Rouge, LA 70821-4312

(225) 219-3041


Addendum to Permit Applications per

LAC 33:I.1701




Please

Type

Or

Print

Company Name
     

 Owner
 Operator
For Permits Division Use Only

Parent Company (if Company Name given above is a division)

     

Plant name (if any)

     

Nearest town

     

Parish where located

     




  1. Does the company or owner have federal or state environmental permits identical to, or of a similar nature to, the permit for which you are applying in other states? (This requirement applies to all individuals, partnerships, corporations, or other entities who own a controlling interest of 50% or more in your company, or who participate in the environmental management of the facility for an entity applying for the permit or an ownership interest in the permit.)

 Permits in Louisiana. List Permit Numbers:      




 Permits in other states (list states):      






  1. Do you owe any outstanding fees or final penalties to the Department? No Yes

If yes, please explain.      

     




  1. Is your company a corporation or limited liability company? No Yes If yes, attach a copy of your company’s Certificate of Registration and/or Certificate of Good Standing from the Secretary of State.


Certification:

I certify, under provisions in Louisiana and United States law which provide criminal penalties for false statements, that based on information and belief formed after reasonable inquiry, the statements and information contained in this Addendum to the Permit Application, including all attachments thereto are true, accurate, and complete.


Responsible Official

Name

     





City

     


State

     


Zip

     


Title

     





Business phone

     


Company

     





Signature of responsible official(s)


Suite, mail drop, or division

     





Date


Street or P.O. Box

     











form_7037_r03

1/1/06


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