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:
Business Phone Cell (Optional) E-mail (Optional) 9. Description and Service Areas Maximum quantities of waste disposed: If ‘Other’ is filled out, provide a brief description of the waste here: Approximate percentage of waste received from onsite: offsite from generators within Louisiana: offsite from generators outside of Louisiana: serviced by the facility: Only waste generated by the facility All parishes Out-of-state Acadia Allen Ascension Assumption Avoyelles Beauregard Bienville Bossier Caddo Calcasieu Caldwell Cameron Catahoula Claiborne Concordia De Soto East Baton Rouge East Carroll East Feliciana Evangeline Franklin Grant Iberia Iberville Jackson Jefferson Davis Jefferson La Salle Lafayette Lafourche Lincoln Livingston Madison Morehouse Natchitoches Orleans Ouachita Plaquemines Pointe Coupee Rapides Red Richland Sabine St. Bernard St. Charles St. Helena St. James St. John the Baptist St. Landry St. Martin St. Mary St. Tammany Tangipahoa Tensas Terrebonne Vermilion Vernon Washington Webster West Baton Rouge West Carroll West Feliciana Winn Other Provide the maximum days of operation per week and per facility operating day (maximum hours of operation within a 24-hour period). days/week hrs/day Provide the normal days or operation per week and hours per facility operating day (within a 24-hour period). days/week hrs/day 10. Enforcement Actions