Ohio Epa 4496 Form PDF Details

Are you an Ohio business or individual wondering what the EPA 4496 Form is? You may have heard different referencse to this document in conversations detailing environmental control, but it’s important to understand exactly what it is and why it matters. The Ohio Environmental Protection Agency created this form to recognize certain properties as eligible for environmentally beneficial projects like remediation, pollution prevention and waste transfer management. We'll provide a comprehensive explanation of the form's purpose and how your business can benefit from its submission.

QuestionAnswer
Form NameOhio Epa 4496 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesco permittee noi, epa, coverage, under

Form Preview Example

Co-Permittee Notice of Intent for Coverage Under

Ohio EPA Storm Water Construction General Permit

Submission of this NOI constitutes notice that the party identified in Section I of this form intends to be authorized by Ohio’s NPDES general permit for storm water associated with construction activity. Becoming a permittee obligates a discharger to comply with the terms and conditions of the permit. NOTE: All necessary information must be provided on this form. Read the accompanying instructions carefully before completing the form. Do not use correction fluid on this form. Forms transmitted by fax will not accepted. There is no fee associated with submitting this form.

I.Applicant Information/Mailing Address

Company (Applicant) Name:

Mailing (Applicant) Address:

__________________________________________________________________________________

City:

 

 

 

State:

 

 

Zip Code:

 

Contact Person:

 

 

Phone:

 

 

 

Fax:

 

Contact E-Mail Address:

 

 

 

 

 

 

 

 

 

 

 

II. Facility/Site Location Information

Existing Ohio EPA Facility Permit Number: ______________________________

 

 

 

 

 

 

Initial Permittee Name:

 

 

 

 

 

 

 

 

 

Phone:

 

 

Facility/Site Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

Township(s):

 

 

 

 

 

 

 

 

County(ies):

 

 

 

State:

 

Ohio

 

 

Zip Code:

 

 

Facility Contact Person:

 

 

 

Phone:

 

 

 

 

Fax:

 

 

Facility Contact E-Mail Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. Certification

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.

Applicant Name:

 

Title:

 

 

Applicant Signature:

 

 

 

Date:

 

 

EPA 4496 (Rev. 2/10)

CLICK TO CLEAR ALL ENTERED INFORMATION

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epa writing process detailed (portion 1)

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Part number 2 in filling in epa

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