2500-FM-BWM0210
6/2005
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGGMENT
FORM 42
APPLICATION FOR REIMBURSEMENT GRANT FOR
INDEPENDENT REVIEW OFMUNICIPAL WASTE PERMITS
Date Prepared:
General Reference: 277.371, 272.372, 272.373
I.D. Number:
Municipality Name:
Address:
City, Township, Borough:
State:
Zip:
Contact Person (Name):
Telephone Number: (
1.
)
-
Federal I.D.#:
Indicate the type of facility for which the permit evaluation was conducted.
Municipal Waste Landfill
2.
Resource Recovery Facility
USGS Map Location of Facility:
7.5’ Map Name:
Latitude:
3.
°/
(Attach an 8½ x 11 copy of Site Location)
'/
"
Longitude:
°/
'/
"
General Information:
Facility Name (if applicable):
Total Acres of the Property:
Number of New Acres Proposed for Permit:
Number of Previously Permitted Acres:
4.
Of permit application is for a municipal waste landfill, indicate the phase for which an independent evaluation was
conducted.
Phase 1
Phase 2
Both
5.
For Phase 1, indicate the areas for which an independent evaluation was conducted.
Facility plan
Groundwater quality description
Maps and related information
Soil description
Description of geology, soils and hydrology-
Surface water information
general requirements
Alternative water supply information
Geology and groundwater description
Mineral deposit information
Other
6.
For Phase 11, indicate the areas for which an independent evaluation was conducted.
Operation plan
Soil erosion and sedimentation control plan
Maps and grid requirements
Water quality monitoring plan
Plan for access roads-
Surface water information
Access control plan
Liner system and leachate control plan
2500-FM-BWM0210
6.
6/2005
For Phase 11, indicate the areas for which an independent evaluation was conducted. (continued)
Nuisance control plan
Leachate treatment control plan
Liter control plan
Modifications of leachate treatment plan
Compaction and cover plan
Gas monitoring and control plan
Revegetation plan
Contingency plan for emergency procedures
Postclosure land use plan
Closure plan
Other
7.
If permit application is for a Resource Recovery Facility, indicate the areas for which an independent evaluation
was conducted.
Operation plan
Erosion and sedimentation control plan
Maps and related information
Nuisance and liter control plan
Plan for access roads-
Contingency Plan
Design and related information
Other
Plan for access roads
8.
Provide a copy of the final report that includes findings, recommendations, etc. submitted by the professional
engineer/consultant to the municipality.
9.
Provide a brief description of the engineer’s professional qualifications and experience regarding municipal waste
landfills or resource recovery facilities (include names of facilities and dates of experience).
10. Attach a copy of the contract or agreement entered into by the municipality and the professional
engineer/consultant.
11. Attach copies of all invoices paid to the professional engineer/consultant by the municipality.
12. Complete Professional Certification Form.
Affidavit must be completed and signed before a Notary Public by the Contact Person named on the
preceding page. In the case of second class townships, the township seal may be affixed hereto with the
contact persons signature in lieu of the seal of a Notary Public, only in cases where this action has been
approved by the Township Supervisors.
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
I,
, being duly sworn according to law, depose and say that I am an Official of the Applicant and that the
information included in the Application and Documents submitted as a part of the Application are true and correct to
the best of my knowledge and belief.
Sworn to and subscribed before me this
day of
, 20
Signature of Notary Public
.
Signature of Local Agency Official
MY COMMISSION EXPIRES
Title
SEAL
Page 2 of 3
2500-FM-BWM0210
6/2005
PROFESSIONAL CERTIFICATION
12.
(continued)
Professional Engineer
I,
, being a registered professional engineer in accordance with the Pennsylvania
Professional Engineer’s Registration Management Act, do hereby certify that the administratively complete permit
application of the
was evaluated in accordance with the accepted practice
of engineering and requirements identified in the Rules and Regulations of the Pennsylvania Department of
Environmental Protection, Title 25, Chapter 271 (Municipal Waste Management-General Provisions) and
Chapter 273 (Municipal Waste Landfills).
Signature
Date
Address
Telephone No. (
Professional
Seal
)
Page 3 of 3