IMPORTANT: Please type or print with black ink when completing all forms; do not use pencil. The signatures must be handwritten, not electronically signed.
Nebraska Administrative Code Title 129, Chapter 9, Section 001.01B allows for an administrative permit amendment for a change in the name, address, or telephone number of any person identified in an air pollution permit, provided that the owner or operator has not changed.
Title 129, Chapter 9, Section 001.01D allows for a change in ownership or operational control through an administrative permit amendment where the Department (NDEE) determines that no other change in the permit is necessary, provided that a written agreement containing a specific date for transfer of permit responsibility, coverage, and liability between the current and new permittee has been submitted. An example agreement would be a written sale agreement which includes the date of property transfer and that is signed by a responsible official for both the buyer and the seller.
Although use of this form is not a requirement, it was created to help streamline an administrative permit amendment for a name change or transfer in ownership or operational control. Use of this form will help ensure that you provide all necessary information. Questions about this form or appropriate documentation can be directed to firstname.lastname@example.org or calling the Air Quality Program at (402) 471-2189. A fillable form and that you can complete offline, print, and submit is available from the NDEE website (http://dee.ne.gov/).
Complete pages 1 and 2 of this form to provide required owner and facility-specific information and pages 3 and 4 to provide information needed for the NDEE to evaluate and process the request for administrative permit amendment. You may use one form when the request involves one NDEE facility identification number (Facility ID) and is for a change in ownership or operational control, or for a name change on multiple permits, where the change is from one current owner to one new owner. Pages 1 and 2 must always be included with the form submittal. In situations that involve a transfer of ownership or operational control, the information provided on pages 1 and 2 must be for the BUYER/TRANSFEREE of the source of air pollution. Incomplete or inaccurate information will delay processing of the request.
1) Enter the NDEE facility identification number (Facility ID). If the Facility ID is unknown, leave this box blank.
2) A permitting action will only be issued to an owner or operator that meets the definition of “person” in Title 129, which is defined as follows: “Person shall mean any: Individual; partnership; limited liability company; association; public or private corporation; trustee; receiver; assignee; agent; municipality or other governmental subdivision; public agency; other legal entity; or any officer or governing or managing body of any public or private corporation, municipality, governmental subdivision, public agency, or other legal entity.” If the “person” listed as the new owner is a corporation, limited liability company, or partnership registered with the Nebraska Secretary of State (NSOS), the name provided in the “New Owner Information” section must be the same as the name registered with the NSOS. For further information concerning NSOS registration requirements, please see http://www.sos.ne.gov/dyindex.html or contact the NSOS. If the “person” listed as the new owner is a partnership that is not registered with the NSOS, please provide the name of the partnership and indicate that the name is that of a partnership. Note that only a partner can sign as a responsible official for a partnership. If the owner is an individual, enter the individual’s name as the owner and also complete and submit a U.S. Citizenship Attestation Form, which can be found on the NDEE website or is available upon request.
3-6) Provide the mailing address of the new owner.
7) If the new owner is a business, indicate whether or not the business is incorporated. If the business is incorporated, provide the name of the state where the business is incorporated.
8) Enter the common name of the source, which may differ from the name of the owner. The source may have a common name that is a trade name, d/b/a (doing business as), or some other name that is not registered with the Secretary of State or that does not meet the definition of “person.” For example, an owner may have multiple sources with different names for each location (e.g., Big Grain - Hastings Location; Big Grain – Kearney Location, etc.). In the case of municipalities, the owner or “person” for the application would be the municipality (e.g., City of Hastings), whereas the common name of the source for a municipality may be the facility or source being permitted (e.g., City of Hastings - Municipal Power Plant). If the New Owner Name and the Common Name of Source are the same, then print or type that name on this line.
9) Provide the source description. This is a general description of the primary activities conducted at the source.
10) Enter the primary, secondary (if applicable), and tertiary (if applicable) 4-digit Standard Industrial Classification (SIC) code(s) associated with your source. If you are uncertain, you can determine the SIC code(s) at http://www.osha.gov/pls/imis/sicsearch.html.
11) Enter the North American Industry Classification System (NAICS) code(s) for your source. If you are uncertain, you can determine the NAICS code(s) at http://www.census.gov/eos/www/naics/.
12-16) Enter the physical address of the source including the street address, city, zip code, county, and legal description of the property (i.e. SE ¼, SW ¼, Sec 2, T 9N, R 14W).
17-22) If the source is located on leased property then check “Yes” and complete #18 through #22. Otherwise, check “No” and proceed to #23.
Source Contact Information
23-28) Provide the name, title, and contact information for the source’s contact person. This is the individual(s) that can answer questions the NDEE may have concerning the source or this request for administrative permit amendment.
29-35) If you prefer the NDEE route questions to an additional contact, such as a consultant or company Environmental Manager, etc., check the Yes box in 29 and enter the name and contact information of the additional contact person (#30-#35).
Responsible Official Certification
36) Each administrative amendment request must include a compliance certification signed by a “responsible official” that states the source is in compliance with the applicable requirements identified in the request and will continue to be in compliance with the requirements. If the source is not in compliance with one or more applicable requirements, the owner or operator must complete and follow an approved compliance schedule until compliance with the requirement in question is achieved. The “responsible official” must also certify that the owner or operator of the source will comply in a timely manner with all new applicable requirements that become effective during the term of the permit. The “responsible official” must check the compliance certification box (#36) to certify the source’s compliance.
37) The required truth and accuracy certification must be checked by the responsible official to certify the contents of the amendment request.
38) The request, which includes both of the above certifications, must be signed and dated in ink by a responsible official as defined in Title 129, Chapter 1. Include the printed name of the responsible official and that person’s title. The request is incomplete without a proper signature. An administrative permit amendment for change of ownership or operational control must be signed by a responsible official of the BUYER/TRANSFEREE.
To request a name change only to the owner name or the common name of the source without a change in ownership or operational control, complete and submit pages 1, 2, and 4. The change in name can be for the owner, common name of source, or both. If the name of the owner is being changed, you must submit documentation to show that new owner is registered and in good standing with the Nebraska Secretary of State (NSOS), provided that registration with NSOS is required. For questions about NSOS registration requirements, please contact the NSOS.
To request an administrative air permit amendment for a change in ownership or operational control complete and submit pages 1, 2, and 3. Please provide the permit numbers for all active air construction permits and active air operating permit the request for administrative permit amendment relates to or affects. Please note that a “responsible official” for both the buyer and seller of the source must sign page 3 of the request for a change in ownership or operational control. “Responsible official” is as defined in Title 129, Chapter 1.
If additional information is submitted, such as a sale agreement or NSOS documentation, please include the NDEE Facility ID# (see item #1 above) at the top of each page to identify the information belongs with this form submittal.
If there are questions about the form or which air permit number(s) to include in your request, please call the Air Quality Program at (402) 471-2186.
If you plan to submit information you consider confidential, please complete the Confidentiality Request form, which is available on the NDEE website, and submit it along with the required information as described in the form. A request for confidentiality must be made in accordance with Nebraska Administrative Code Title 115 – Rules of Practice and Procedure. Please note that a claim of confidentiality is subject to the Director’s determination and approving confidentiality is not guaranteed. Generally, confidentiality claims must be resolved before the Department will begin processing the related submittal.
Submit your request as follows:
Attn: Air Permitting Section Supervisor
Nebraska Department of Environment and Energy
PO Box 98922
Lincoln, NE 68509-8922
Attn: Air Permitting Section Supervisor
Nebraska Department of Environment and Energy
245 Fallbrook Blvd, Suite 100
Lincoln, NE 68521
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Produced by: Nebraska Department of Environment & Energy, P.O. Box 98922, Lincoln, NE 68509-8922;
phone (402) 471-2186. To view this, and other information related to our agency, visit our web site at http://dee.ne.gov.