Address Phone # Address Phone # Address Phone # Address Phone # - 2 -

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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF WASTE MANAGEMENT

Application for Registration

Household/Small Business Hazardous Waste Collection Program

If you have questions filling out this form, please call your regional office listed in the directions that

accompanied this form or call (717) 787-7382.

1. Applicant/Sponsor Name

Address

Lead contact Person and Title Telephone Number

email address

2. Date(s) of event From To

3. Applicant / Sponsor is: Single municipality Person/company

Lead municipality for multi-municipality sponsored program. List other sponsors below.

1. 2.

3. 4.

Other (please specify) 4. Grant Application Information - Please check the appropriate box

Grant being requested - grant application attached

Grant being requested – application will be submitted after collection event No grant being requested

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5. Collection Contractor Information

Name of Contractor #1

EPA Identification # Permit Expiration Date

Lead Contact Person Title

Address Phone #

City State Zip

Address Phone #

City State Zip

Address Phone #

City State Zip

Address Phone #

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6. Transporter Company Information

Name of Transporter #1

PA Transporter License # Expiration Date

Address Phone #

City State Zip

Address Phone #

City State Zip

Address Phone #

City State Zip

Address Phone #

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7. Collection Site Information

Location #1 EPA ID#

Date(s) of event From To

Estimated number of small

business participants Storage site Estimated number of household participants Cosponsor Transporter Contractor

Location #2 EPA ID#

Location #3 EPA ID#

Location #4 EPA ID#

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8. Waste Estimates

Location

Collector EPA ID

Estimated number of participating SQGs and CESQGs Estimated number of participating households

For each type of waste that is expected to be collected at each location, please enter the following:

Type of Waste EPA Hazardous Waste ID# Estimated lbs. collected

1. Latex Paint

2. Oil Based Paint

3. Paint

Products/Turpentine

4. Corrosives/Caustics

5. Pesticides/Poisons

6. Chlorine Products

7. Used Oil

8. Flammable Liquids

9. Antifreeze

10. Lead Acid Batteries

11. NiCad Batteries

12. Asbestos

13. Other

Conversions

Assume 8 pounds equals 1 gallon

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9. Site Description and Management Plan

A. Attach a 7 ½ inch USGS quadrangle map showing the general location of each site and a paragraph describing the proximity of adjacent properties, including the locations of the nearest residences and/or institutional facilities. B. Attach an 8 ½ by 11 inch plan of the collection/sponsor storage site that shows the separation of work areas.

Include a discussion on people and traffic control. This statement should include entrance/exit information, identification of collection personnel, and how unloading, mixing, placement and loading will be handled.

C. If the site is not owned by the sponsor, a “Site Use Authorization Statement” must be attached that indicates the owner has given the sponsor permission to use the location to conduct the event.

10. Site Safety and Contingency Plan

A Site Safety and Contingency Plan is required. At a minimum, it must include: a. Compliance with Items of Chapter 272.514.

b. Evidence of a minimum of $2.0 million general insurance liability coverage. c. Program provisions to prevent spills.

d. Plans for managing and cleaning up spills.

e. Provisions for preventing explosions, fires, and releases of toxic or hazardous substances. f. Emergency equipment and personnel available on site.

g. Qualifications of personnel operating the collection event, including safety training. h. Security arrangements for overnight storage.

i. For permanent storage facilities, evidence of compliance with any applicable municipal zoning requirements and approval by the local fire department.

11. Attach a Negotiated Contract

Attach negotiated contracts with collection contractors to be used by the program. The contracts do not need to be signed at the time of this application. As a minimum, the contract must meet the requirements of Chapter 272.513.

12. Reuse and Recycling

Whenever possible, the reuse and recycling of collected materials should be encouraged. Describe the steps that will be taken to minimize the amount of waste that will be disposed from the event.

13. Public Education

Attach a description and/or examples of public education materials that will be distributed at the collection event emphasizing pollution prevention in the home, source reduction through the use of alternative less toxic materials, recycling, proper disposal methods for material that can not be recycled, and/or home safety or fire prevention. Contact your regional office for educational materials that may already be available for your program. Other education information may be found on the Department’s website (www.dep.state.pa.us) or through the National Environmental Hotline (1-800-CLEAN-UP or www.1800cleanup.org).

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14. Management of Waste

Attach a written confirmation from the collection contractor(s) affirming that the hazardous waste collected at the event will be sent for reclamation, treatment or disposal.

Enter the following information for facilities that will be accepting the collected waste for final reclamation, treatment or disposal.

Facility Name

Location (city and state)

Hazardous Waste Permit # Permit Expiration Date Hazardous Waste ID #'s Accepted 15. Grant Estimate

Please make your best estimate as to the amount of grant funds you will be applying for upon completion of the collection event. The grant amount is calculated by multiplying the amount by 50%.

This section does not constitute an application for reimbursement. A separate Reimbursement Application is to be submitted upon completion of the program.

Cost Category Amount ($)

Grant Amount

1. Wages

2. Employer Costs (Soc. Sec., unemployment comp., etc.)

3. Training 4. Lodging 5. Subsistence 6. Facility/supplies/equipment 7. Operational 8. Total

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16. Certification

This is to certify that I have personally examined and am familiar with the information in this application and attached documents. I have reviewed the legislation and regulations that pertain to household/small business hazardous waste collection and disposal programs and I am aware of the Department of Environmental Protection’s requirements for this application. To the best of my knowledge, the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information

Sworn to and subscribed before me

This day of ,

notary public Signature of Sponsor’s Authorized Official

seal

For Department Use Only

Received by Date

Reviewed by Date

Approved by Date