2520-FM-BWM0608 Rev. 9/2014
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
Covered Device Recycling Act (CDRA) Act 108 of 2010
Manufacturer of Covered Electronic Devices
Registration Form for Calendar Year 2015
REGISTRATION FEE - $5,000
I.
MANUFACTURER INFORMATION
Company Name (Include All Fictitious Business Names)
Manufacturer of:
Desktop/Notebook Computer
(includes tablets and e-readers
with internet browsing capabilities)
Computer Monitor
Computer Peripheral
Television
US Corporate Headquarters
Mailing Address:
Telephone:
City:
State:
Zip:
Home Website Address:
II.
CONTACT INFORMATION
Name (Print):
Check here if the same as the above corporate address.
Title:
Mailing Address:
E-Mail:
Telephone:
City:
State
III.
Zip:
MANUFACTURER BRANDS & COVERED DEVICES
Brand Name
[Attach additional sheets if necessary]
Desktop/Notebook
Computer
Including Tablets etc.
Computer
Monitor
Computer
Peripheral
Check here if attaching any additional sheets.
-1-
Television
2520-FM-BWM0608
Rev. 9/2014
THIS PAGE
EXEMPT FROM DISCLOSURE UNDER THE PROVISIONS OF
THE PA RIGHT-TO-KNOW-LAW
THE ACT OF FEBRUARY 14, 2008 (P. L. 6, NO. 3)
IV.
ESTIMATE BY WEIGHT (POUNDS) OF COVERED DEVICES SOLD TO CONSUMERS IN THE UNITED
STATES IN 2013
Desktop/
Notebook
Computer
(Includes
tablets, etc.)
Brand Name
Computer
Monitor
Computer
Peripheral
Television
Brand Total
(lbs.)
(lbs.)
(lbs.)
(lbs.)
(lbs.)
Total (lbs.)
Use .0406 (Pennsylvania population/national population) as the multiplier to
determine the pounds attributed to sales in Pennsylvania. Pennsylvania-specific
sales data is no longer accepted.
V.
lbs.
STATEMENT OF NON-APPLICABILITY
Act 108 of 2010, the Covered Device Recycling Act, does not apply to the manufacturer covered by this
registration
Choose the reason for non-applicability from the list below. If necessary, provide an explanation in the space
provided, and DO NOT SUBMIT THE REGISTRATION FEE.
1)
The company identified on this registration form does not meet the definition of a manufacturer.
(Explanation required below)
2)
In the calendar year covered by this form, the manufacturer will not sell covered devices in Pennsylvania
for consumer use.
3)
The manufacturer identified on this form is no longer in business and has no successor in interest.
4)
Other reason as explained below.
Please Explain.
-2-
2520-FM-BWM0608 Rev. 9/2014
VI.
CERTIFICATION OF COMPLIANCE
By signing below, I certify that I am an authorized official of the manufacturer and have completed this form
truthfully and the information on this form is accurate and complete and based on records maintained by this
company. In addition, I am certifying that the manufacturer is in compliance with the requirements of Act 108 of
2010 — the Covered Device Recycling Act. I further declare that all material will be managed at appropriately
certified and permitted electronics recycling facilities as required under the CDRA.
Signature
__________________________________
Date
__________________________
Print Name
______________________________________________________________________
Title
______________________________________________________________________
Organization name or registered fictitious name (if not the manufacturer identified on the form)
E-Mail address:
__________________________________________________________________
Telephone:
VII. ENCLOSE $5,000 REGISTRATION FEE ALONG WITH THIS FORM
Make the check payable to the Commonwealth of Pennsylvania. No electronic payments will be accepted. A W-9
Form for the PA Department of Environmental Protection is attached.
VIII. MAILING INSTRUCTIONS:
If by US Postal Service:
If by Ground Service (UPS, RPS, etc.)
Or Hand Delivered:
PA Department of Environmental Protection
Bureau of Waste Management
PO Box 8472
Harrisburg, PA 17105-8472
PA Department of Environmental Protection
Bureau of Waste Management
400 Market Street – 14th Floor
Harrisburg, PA 17101-8472
For Additional Information contact:
Jeff Bednar, Program Specialist
Waste Minimization and Planning
Bureau of Waste Management
PA Department of Environmental Protection
Telephone 717-787-7382
jbednar@pa.gov
DEP website: www.dep.state.pa.us, (select ‘Electronics Recycling’ from the ‘DEP Programs A – Z’ menu)
-3-