Yes No Does the applicant owe any outstanding fees or final penalties to the LDEQ? If “yes”, provide an explanation. Yes No Is the applicant a corporation or limited liability company? If attach a copy of the Certificate of Registration and/or Certificate of Good Standing from the Secretary of “yes,” Attachment 4. State. Attach the appropriate certificate(s) in 7. Certification and Signatures have personally examined and am familiar with the information CERTIFICATION OF RESPONSIBLE OFFICIAL: “I submitted in the attached document, and I hereby certify under penalty of law that this information is true, accurate, and complete to the best of my knowledge, information, and belief. I am aware that there are significant penalties for submitting false information, including the possibility of fine and/or imprisonment.” Name Title Company Suite, mail drop, or division Street or P.O. Box City State Zip Business Phone Signature of responsible official (as defined in LAC 33:VII.115): Date: CERTIFICATION OF APPLICATION PREPARER: "I certify penalty of law that I have personally examined and I am familiar with the information submitted in this permit application and that the facility as described in this permit application meets the requirements of LAC 33:VII.Subpart 1. I am aware that there are significant penalties for knowingly submitting false information, including the possibility of fine and imprisonment." Name Company Suite, mail drop, or division Street or P.O. Box City State Zip Business phone Cell Phone (Optional) Email (optional) Signature of preparer: Date: CERTIFICATION OF ENGINEER: "I certify that the facility plans, specifications, and operations represented and described in the permit application were prepared under my supervision and are true and accurate to the best of my knowledge, information, and belief in accordance with LAC 33:VII.715.B.1." Name Title Company Suite, mail drop, or division Street or P.O. Box City State Zip Business Signature of engineer: Date: Louisiana Registration Number and Seal:
Does the applicant owe any outstanding fees or final penalties to the LDEQ? Yes No If “yes”, provide an explanation. Is the applicant a corporation or limited liability company? Yes No If “yes,” attach a copy of the Certificate of Registration and/or Certificate of Good Standing from the Secretary of State. Attach the appropriate certificate(s) in Attachment 4. 7. Certification and Signatures CERTIFICATION OF RESPONSIBLE OFFICIAL: “I have personally examined and am familiar with the information submitted in the attached document, and I hereby certify under penalty of law that this information is true, accurate, and complete to the best of my knowledge, information, and belief. I am aware that there are significant penalties for submitting false information, including the possibility of fine and/or imprisonment.” Name Title Company Suite, mail drop, or division Street or P.O. Box City State Zip Business Phone Signature of responsible official (as defined in LAC 33:VII.115): Date: CERTIFICATION OF APPLICATION PREPARER: "I certify penalty of law that I have personally examined and I am familiar with the information submitted in this permit application and that the facility as described in this permit application meets the requirements of LAC 33:VII.Subpart 1. I am aware that there are significant penalties for knowingly submitting false information, including the possibility of fine and imprisonment." Name Company Suite, mail drop, or division Street or P.O. Box City State Zip Business phone Cell Phone (Optional) Email (optional) Signature of preparer: Date: CERTIFICATION OF ENGINEER: "I certify that the facility plans, specifications, and operations represented and described in the permit application were prepared under my supervision and are true and accurate to the best of my knowledge, information, and belief in accordance with LAC 33:VII.715.B.1." Name Title Company Suite, mail drop, or division Street or P.O. Box City State Zip Business Signature of engineer: Date: Louisiana Registration Number and Seal:
Type%20I-II%20Landfarm%20Permit%20App%202014.docx