Supplemental Application Form For Hazardous Waste printable pdf download

SUPPLEMENTAL APPLICATION

FOR

HAZARDOUS WASTE TRANSPORTERS ONLY

APPLICANT NAME:

MAILING ADDRESS:

PHONE NUMBER:

ROUTINE CONTACT:

EMERGENCY CONTACT:

ALTERNATE EMERGENCY CONTACT:

EPA IDENTIFICATION NUMBER:

(Note: If you have not been issued an EPA ID. #, your application must include a completed USEPA Notification of

Hazardous Waste Activity Form, which will result in the issuance of an EPA Id. No. If you need a copy of this form,

contact the Waste Management Division at (802)241-3888.)

G Used Oil

G Hazardous Waste

TYPES OF WASTE:

G Transporter of Own Wastes Only

G Transporter for Commercial Purposes*

*Local Contact Name & Telephone: ____________________________________________

*Local Contact Town & State: _________________________________________________

10.

METHOD(S) OF HAZARDOUS WASTE TRANSPORT (Check all that apply):

non-bulk liquids (<3,500 water gallons) (MCS-90 form indicating $1 million primary

insurance is required)

bulk liquids (>3,500 water gallons) (MCS-90 form indicating $5 million primary

insurance is required)

drummed solids (MCS-90 form indicating $1 million primary insurance is required)

other solids (MCS-90 form indicating $1 million primary insurance is required)

STATEMENT OF REQUIRED TRAINING AND LIABILITY INSURANCE REQUIREMENTS :

11.

I certify that all employees involved in the pick up or delivery of regulated hazardous wastes in Vermont have

been trained in accordance with the Federal Code of Regulations Title 49 Parts 170-199 and Parts 390-399 and

the Vermont Hazardous Waste Management Regulations Section 7-409.

I further certify that the appropriate insurance coverage, including an MCS-90 endorsement, for the required

amounts checked in #10, above, and in accordance with the Vermont Hazardous Waste Management

Regulations Section 7-410, is in full force and effect and shall be maintained in full force and effect during the

term of the permit.

Print/Type Name & Title

Signature

Date

*Note: This information will be used for the purpose of generating a list of commercial hazardous waste transporters permitted in

Vermont. This information is frequently requested by generators and consultants.

Supplemental Application Form For Hazardous Waste