Contact Information Update Form

Contact Information Update Form

This form is for the update of company/source contact information only.
Company Name*
Facility ID*
5-digit number located on any Permit to Operate
Site Address (Optional)

Site Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MAILING & BILLING ADDRESS CHANGE

To update a mailing and/or billing address, please complete a Mailing & Billing Address Change Application and email to payments@ysaqmd.org. There is a fee to update a mailing address and the fee is charged per facility location. Please refer to the current fee schedule for our Mailing Address Change Fee. There is no fee to update a billing address.

COMPANY NAME/OWNERSHIP CHANGE

To update the company name or if ownership of this facility has changed, please complete a Transfer/Name Change Application and email to payments@ysaqmd.org. There is a fee to process a Company Name Change or Ownership Change. Please refer to the current fee schedule for our Company Name/Ownership Change Fee.
INSTRUCTIONS & DEFINITIONS

All facilities must have one and only one “Main” contact. The “Main” contact can be anyone in the company, however typically this contact is an owner, president, manager, or other individual with the authority to certify that the facility complies with all applicable requirements and conditions of permits issued by the District. This is also the contact with signature authority for permit applications and other official forms.

The following contact types are optional. If any of these contact types are not identified, the District will default to the “Main” contact:
- "Site” Contact: An individual who works at the facility site, who typically interacts with District staff regarding inspections.
- “Throughput” Contact: This individual will receive all email correspondence regarding submittal of annual throughputs for each of the facility permits.
- “Billing” Contact: Billing invoices are normally send to the billing address, not to the attention of an individual. Billing questions will be directed to this contact.
- “Mailing” Contact: This individual will receive all official correspondence from the District, with the exception of billing correspondence as mentioned above.
- “Other” Contact: This can be any individual associated with the facility that interacts with District staff.
Contact Type*
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Additional Contact Type (optional)
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Additional Contact Type (optional)
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Additional Contact Type (optional)
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Additional Contact Type (optional)
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Additional Contact Type (optional)
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Additional Contact Type (optional)
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Additional Contact Type (optional)
Contact Information

Name

Title

Phone Number w/extension/Direct LineMobile Number

Email Address
Email
example@example.com
Completed by:*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Signature*

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