NOTIFICATION FORM ON OWNERSHIP TRANSFER OF FLUORESCENT LAMPS, HIGH-
INTENSITY DISCHARGE LAMPS, AND LIGHT FIXTURES FROM BUILDING
DEMOLITIONS
The prospective buyer/recipient identified below has expressed interest in obtaining used fluorescent lamps, high-intensity discharge lamps, and light fixtures from Minnesota Department of Transportation
(MnDOT) building demolition projects for reuse. The Minnesota Pollution Control Agency regulates the waste management of used fluorescent lamps, high-intensity discharge lamps, and light fixtures. By signing this document, the buyer certifies that he or she is familiar with proper handling and disposal of this material. The buyer must complete this form to MnDOT’s satisfaction prior to removal of any used fluorescent lamps, high-intensity discharge lamps, and light fixtures. Any change in the method or location of re-use of the materials would require re-submittal and approval.
Source of used fluorescent lamps, high-intensity discharge lamps, and light fixtures material:
_____
_____ MnDOT Contract:
Buyer:
(name, company, mailing address, telephone number)
_____
_____
Description Quantity
Date
Transferred
Comments
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Buyer assumes all risk and agrees to hold harmless, defend, and indemnify MnDOT for any claim that may be brought against it by any individual, entity, or governmental agency pursuant to any local, state, or federal law or regulation or pursuant to decisional law that is based upon a release or threatened release of a hazardous substance or a pollutant or contaminant occurring on or in the Property. In addition to requests for monetary compensation, the term “claim” as used herein includes, but is not limited to, demands to MnDOT for clean up or remediation costs, fines, and costs and expenses, including attorneys’
I fees.
(Print name of authorized buyer)
certify that the following information is correct:
The above used fluorescent lamps, high-intensity discharge lamps, and light fixtures will be reused in the following manner:
_____________________________
_____
I also certify that
(Buyer name)
is familiar with Local, State and Federal requirements, including the Minnesota Pollution Control Agency fact sheet “Fluorescent Lamps, High-
Intensity Discharge Lamps, and PCB Ballasts”, regarding proper handling and disposal of this material and the buyer has been notified that used fluorescent lamps, high-intensity discharge lamps, and light fixtures are regulated by the MPCA.
_____
(Buyer signature) (Date)
Received by MnDOT representative:
(Signature)
(Print name)
(Date)
_____
_____
Stewardship
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