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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WASTE MANAGEMENT Application for Registration Household/Small Business Hazardous Waste Collection Program If you have

1 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) Applicant/Sponsor Name Address Lead contact Person and Telephone Number address 2. (s) of event From To 3. Applicant / Sponsor is: Single municipality Person/company Lead municipality for multi-municipality sponsored program. List other sponsors below 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 -

Applicant/Sponsor Name Address Lead contact Person and Telephone Number email address 2. (s) of event From To 3.

2 5. Collection Contractor Information Name of Contractor #1 EPA Identification # Permit Expiration Name of Contractor #2 EPA Identification # Permit Expiration Name of Contractor #3 EPA Identification # Permit Expiration Name of Contractor #4 EPA Identification # Permit Expiration - 2 -

Identification # Permit Expiration Name of Contractor #3 EPA

3 6. Transporter Company Information Name of Transporter #1 PA Transporter License # Expiration Name of Transporter #2 PA Transporter License # Expiration Name of Transporter #3 PA Transporter License # Expiration Name of Transporter #4 PA Transporter License # Expiration - 3 -

Transporter License # Expiration Name of Transporter #3 PA

4 7. Collection Site Information Location #1 (s) of event From Storage site Cosponsor Contractor To EPA ID# Estimated number of small business participants Estimated number of household participants Transporter Location #2 (s) of event From Storage site Cosponsor Contractor To EPA ID# Estimated number of small business participants Estimated number of household participants Transporter Location #3 (s) of event From Storage site Cosponsor Contractor To EPA ID# Estimated number of small business participants Estimated number of household participants Transporter Location #4 (s) of event From Storage site Cosponsor Contractor To EPA ID# Estimated number of small business participants Estimated number of household participants Transporter - 4 -

participants Transporter Location #3 (s) of event From Storage site Cosponsor Contractor To EPA ID# Estimated number of small business participants Estimated number of household

5 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# Estimated lbs. collected 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 -

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.

6 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 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 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 ( or through the National Environmental Hotline (1-800-CLEAN-UP or

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.

7 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 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 Amount ($) 1. Wages 2. Employer Costs (Soc. Sec., unemployment comp., etc.) 3. Training 4. Lodging 5. Subsistence 6. Facility/supplies/equipment 7. Operational 8. Total Grant Amount - 7 -

Facility Name Location (city and state) Hazardous Waste Permit # Permit Expiration Hazardous Waste ID #'s Accepted 15.

8 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, notary public Signature of Sponsor s Authorized Official seal For Department Use Only Received by Reviewed by Approved by Disapproved by - 8 -

Environmental Protection s requirements for this application. To the best of my knowledge, the submitted information is true, accurate, and complete.

ROGUE VALLEY BUSINESS HAZARDOUS WASTE COLLECTION EVENT. FRIDAY, MAY 6, 2016 at Rogue Transfer Station at 8001 Table Rock Rd.

ROGUE VALLEY BUSINESS HAZARDOUS WASTE COLLECTION EVENT for Oregon Businesses Producing Small Amounts of Hazardous Waste FRIDAY, MAY 6, 2016 at Rogue Transfer Station at 8001 Table Rock Rd. What s Happening?