Attachment N: Certification Regarding Activities Previously Licensed by DEP

Attachment N:Certification Regarding Activities Previously Licensed by DEP

Applicant Name:

(as indicated on the Permit Application Transmittal Form)

Where there has been no change in solid waste activities previously licensed by DEP, certain supporting documents may be incorporated by reference into an application by completing the following certification indicating that no changes have been made to the permitted facility and the supporting documents since the documents were submitted and approved by DEP. The documents that are eligible for incorporation by reference are listed below. You are not required to resubmit such documents unless requested by DEP.

This certification must be signed as indicated in the instructions (DEP-SW-APP-100) under Part VII: Applicant Certification, and shall certify as follows: "I have examined the documents identified by checking the applicable boxes below which were previously submitted for permit issuance to the Department of Environmental Protection for the activities which are the subject of this application, and certify that to the best of my knowledge and belief, no modifications or changes have been made to the permitted facility and supporting documentation since such documents were approved by the Department of Environmental Protection. I further certify that I will submit such documents to the Department of Environmental Protection upon written request."
Please check the appropriate boxes indicating which documents you are proposing to incorporate into this application by reference and provide the latest date that each document was updated.
Background Information: (Applicant/Owner/Operator Info) (DEP-SW-APP-101) / Rev. Date:
Statement of Consistency with Solid Waste Management Plan (DEP-SW-APP-102) / Rev. Date:
Business Information: (DEP-SW-APP-103) / Rev. Date:
Applicant's Financial Stability Information / Rev. Date:
Land Ownership Documents / Rev. Date:
Agreements between all parties involved in the project for the ownership, control, and use of the facility / Rev. Date:
Service agreements and/or contracts with markets, users, final disposal sites, or other processing facilities / Rev. Date:
Planning and zoning approval (required only for applications to construct and operate landfills, incinerators, or resources recovery facilities) / Rev. Date:
Determination of Need Information (DEP-SW-APP-104) / Rev. Date:
Facility Plan (not required for applications to construct and operate a solid waste disposal area, e.g. landfill): / Rev. Date:
Engineering drawings / Rev. Date:
Operation and Management Plan / Rev. Date:
Checklist for Solid Waste Disposal Areas (Landfills) (DEP-SW/WD-APP-110) / Rev. Date:
Signature of Applicant / Date
Name of Applicant (print or type)
Permit Number: / Title (if applicable)

Bureau of Materials Management and Compliance Assurance

DEP-SW-APP-1051 of 1Rev. 01/14/09