Agency of Natural Resources
Waste Management & Pollution Prevention Division
One National Life Drive, Davis 1 Bldg., Montpelier, VT 05620-3704
802-828-1138 FAX: 802-828-1011
CATEGORICAL DISPOSAL CERTIFICATION APPLICATION FORM
March 6, 2006 Revised October 30, 2013
Please print all information requested in sections 1-5 of this form.
1.
Facility, Facility Owner, Operator, and Contact Person Information
A. Facility Name:
Facility 911
Address:
Telephone:
B. Facility Owner:
Mailing Address:
Email:
Telephone:
C. Facility Operator:
Mailing Address:
Email:
Telephone:
D. Landowner:
Mailing Address:
Email:
Telephone:
2.
Type and quantity of wastes accepted for disposal:
Fill in the estimated amounts per year for each waste type accepted by the facility.
a.
b.
c.
d.
e.
f.
g.
h.
Type
Stumps, brush and untreated wood (banned after July 1, 2016)
Bituminous concrete
Rinsed non-recyclable glass
Concrete, masonry, mortar, porcelain, pottery tile, and clay pipe
Street sweepings
Car wash grit and municipal separated storm sewer catch basin grit
Three tons per year (dry weight) or less of dead animal carcasses
Dead wildlife disposal pits or burials established by the Vermont
Department of Fish and Wildlife
Amount (tons/year)
Categorical Disposal Certification Application Form
3.
Days and Hours of Facility Operation
Days:
Days:
Days:
Days:
Days:
4.
Page 2 of 2
Hours:
Hours:
Hours:
Hours:
Hours:
Application Fee
In accordance with 3 V.S.A. 2822(j)(6)(D), categorical disposal applications are subject
to a $100 application fee. Please attach the application fee to this application form.
ATTACHMENTS
The following information must be included with this application form:
a.
A site location map with the location of the facility clearly shown.
b.
A site diagram showing the following features:
1.
facility size and the limits on its development;
3.
location of and the distance to public highways and property lines;
4.
location and distance to Class B waters;
5.
the location of the source isolation zone and the distance to the source of
a public water supply;
6.
the location of any source protection area.
7.
location of and distance to a private water supply
c.
Information which demonstrates that the facility is not located in the following
areas:
1.
class I or II groundwater areas;
2.
watershed for class A waters; and,
3.
in a floodway or in a 100-year flood plain;
d.
Information which demonstrates compliance with the requirements for Class I, II,
and III wetlands and their associated buffers;
e.
A Facility Management Plan that addresses proper operation and development of
the facility in accordance with §6-309(e) of the Rules
f.
Evidence from the appropriate planning entity that the facility is either acceptable
or is included in the solid waste implementation plan, if any;
g.
A copy of the Notice of Application to the Municipality.
SIGNATURES
______________________________________ ___________________________
Landowner
Date
Note: Landowner, your signature constitutes approval to use this site for the categorical disposal facility
______________________________________ ___________________________
Applicant
Date