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 -1- 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 -4- 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 -5- 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). -6- 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 ($) -7- 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 -8-