2520-FM-BWM0214 Rev. 1/2010
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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2520-FM-BWM0214 Rev. 1/2010
5.
Collection Contractor Information
Name of Contractor #1
EPA Identification #
Permit Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
Zip
Name of Contractor #2
EPA Identification #
Permit Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
Zip
Name of Contractor #3
EPA Identification #
Permit Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
Zip
Name of Contractor #4
EPA Identification #
Permit Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
-2-
Zip
2520-FM-BWM0214 Rev. 1/2010
6.
Transporter Company Information
Name of Transporter #1
PA Transporter License #
Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
Zip
Name of Transporter #2
PA Transporter License #
Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
Zip
Name of Transporter #3
PA Transporter License #
Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
Zip
Name of Transporter #4
PA Transporter License #
Expiration Date
Lead Contact Person
Title
Address
Phone #
City
State
-3-
Zip
2520-FM-BWM0214 Rev. 1/2010
7.
Collection Site Information
Location #1
Storage site
EPA ID#
Estimated number of small
business participants
Estimated number of
household participants
Cosponsor
Transporter
Date(s) of event From
To
Contractor
Location #2
Storage site
EPA ID#
Estimated number of small
business participants
Estimated number of
household participants
Cosponsor
Transporter
Date(s) of event From
To
Contractor
Location #3
Storage site
EPA ID#
Estimated number of small
business participants
Estimated number of
household participants
Cosponsor
Transporter
Date(s) of event From
To
Contractor
Location #4
Storage site
EPA ID#
Estimated number of small
business participants
Estimated number of
household participants
Cosponsor
Transporter
Date(s) of event From
To
Contractor
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2520-FM-BWM0214 Rev. 1/2010
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#
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
For lead acid batteries, assume 20 pounds per battery
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Estimated lbs. collected
2520-FM-BWM0214 Rev. 1/2010
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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2520-FM-BWM0214 Rev. 1/2010
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
1. Wages
2. Employer Costs (Soc. Sec.,
unemployment comp., etc.)
3. Training
4. Lodging
5. Subsistence
6. Facility/supplies/equipment
7. Operational
8. Total
Amount ($)
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Grant
Amount
2520-FM-BWM0214 Rev. 1/2010
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
,
Signature of Sponsor’s Authorized Official
notary public
seal
For Department Use Only
Received by
Date
Reviewed by
Date
Approved by
Date
Disapproved by
Date
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