Environmental Pollution Application

ENVIRONMENTAL POLLUTION APPLICATION

WHEREAS

WHEREAS Applicant Name: submits this Environmental Pollution Application to Reviewing Authority Name: for review, permitting, or approval of activities affecting environmental media described herein.

WHEREAS the activities proposed at Site Name: and Site Address: may result in the release, remediation, monitoring, or management of pollutants subject to regulation.

WHEREAS Applicant seeks authorization to proceed with the Scope of Work described below and agrees to comply with all applicable statutes, regulations, permit conditions, and reporting requirements imposed by the Reviewing Authority.

APPLICANT INFORMATION

Individual    Corporation    LLC    Government    Other:

SITE & INCIDENT INFORMATION

Incident Time:    Reported By:

Air    Water    Soil    Hazardous Waste    Noise    Other:

SCOPE OF WORK

The Scope of Work shall include specific tasks, responsible parties, schedules, monitoring plans, containment and disposal methods, and performance standards. Applicant affirms that the proposed measures are sufficient to prevent or mitigate further releases and to restore affected media to regulatory standards where required.

ATTACHMENTS & REPORTING

Required attachments (check and attach where applicable). Applicant certifies that all attachments are accurate and complete.

Remediation / Response Plan    Monitoring Data / Laboratory Reports    Site Map / Aerial Photo    Existing Permits / Approvals    Proof of Fee Payment

PAYMENT TERMS

Applicant agrees to pay application, review, inspection, and monitoring fees as assessed. Failure to remit fees timely may result in suspension of review or permit actions and accrual of interest.

Late fee: . Amounts overdue shall accrue interest at the stated rate compounded monthly until paid. Applicant shall also be responsible for reasonable collection costs and administrative fees arising from delinquent payment.

TERM AND TERMINATION

Term Commencement Date: . Term Expiration Date: .

Either party may terminate this application review or any conditional authorization issued hereunder for cause upon written notice. Notice Period (days): . Immediate termination or suspension may occur where continued activity presents an imminent threat to human health or the environment.

Upon termination, Applicant remains liable for all fees, costs of corrective action, monitoring, and enforcement incurred prior to termination and for any required post-termination remediation.

CONFIDENTIALITY

All information submitted shall be treated in accordance with applicable confidentiality provisions. Information marked confidential will be protected to the extent permitted by law; however, confidentiality shall not apply to (a) information that is already public or becomes public through no breach by the Reviewing Authority, (b) information required to be disclosed by statute, regulation, or court order, or (c) aggregated or summary data that does not identify specific facilities or trade secrets.

Applicant acknowledges that in emergency situations the Reviewing Authority may disclose information to emergency responders, neighboring property owners, or other agencies when necessary to protect public health and the environment.

CERTIFICATION & ACKNOWLEDGMENT

By submitting this application the undersigned certifies under penalty of law that the information provided is true, accurate, and complete to the best of their knowledge. Applicant agrees to permit access and inspection of the Site by authorized representatives for verification, monitoring, or enforcement. False statements, omissions, or misrepresentations may subject the Applicant to civil or criminal penalties.

Applicant further acknowledges responsibility for timely reporting of subsequent conditions, additional releases, or changes to the Scope of Work that may materially affect the risk to health or the environment.

GOVERNING LAW

This Application and any authorization, permit, or agreement arising from it shall be governed by and construed in accordance with the laws of the jurisdiction in which the Site is located. Venue for disputes arising under this Application shall lie in the appropriate court or administrative forum of that jurisdiction.

ENTIRE AGREEMENT

This Application, together with any executed permits, conditions, attachments and written amendments, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior oral or written representations, negotiations, and agreements. Any modification must be in writing and signed by authorized representatives of both parties.

ADDITIONAL REPRESENTATIONS

Applicant represents that it has the authority to execute this Application and bind the entity identified herein. The Reviewing Authority represents only that review and any authorization will be performed consistent with applicable procedures and standards; such review does not create liability on the Authority for failures beyond its control.

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