DTSC Form 1428 "Certified Appliance Recycler Application" - California

What Is DTSC Form 1428?

This is a legal form that was released by the California Department of Toxic Substances Control - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 10, 2019;
  • The latest edition provided by the California Department of Toxic Substances Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DTSC Form 1428 by clicking the link below or browse more documents and templates provided by the California Department of Toxic Substances Control.

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Download DTSC Form 1428 "Certified Appliance Recycler Application" - California

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State of California – California Environmental Agency
Department of Toxics Substances Control
rol
Certified Appliance Recycler Application
Please submit to:
Department of Toxic Substances Control
Attn: HWMP - CAR Application
1001 “I” Street, 11
th
Floor
P.O. Box 806
Sacramento, California 95812-0806
or
CAR@dtsc.ca.gov
Before you may remove “materials that require special handling” (MRSH) from a major appliance, you must be
approved as a Certified Appliance Recycler (CAR), pursuant to Health and Safety Code section 25211 et seq.
(AB 1447, 2007). You must also provide evidence of your CAR status to scrap metal facility.
Once a certificate is issued, DTSC will notify the certified uniform program agency (CUPA) in your jurisdiction
responsible for inspecting the certified appliance recycling facility.
Certificates issued will be valid for three years. Once your certification has expired, you are no longer a CAR
In order to continue operating as a CAR, you must renew your certification before the expiration date.
Please note: Any changes to the information provided on the Certified Appliance Recycler Application must be
submitted to DTSC in order for the certification to be valid.
Renewal CAR Number:
New CAR Number:
Please note: Entire application must be completed.
1. Business Information
Business name under which the applicant operates:
Physical Address:
Mailing Address:
Business Phone Number:
Business Owner Name:
Owner Address:
Owner Phone Number:
Email Address (if available):
2. Hazardous Waste Generator Identification Number:
3. Have filed for a storm water permit?
Yes
or
Not required to obtain
4. Have filed a hazardous materials business plan?
Yes
or
Not required to file
5. Tax identification number, assigned by the Franchise Tax Board:
6. Attach a copy of a business license.
7. Attach a copy of conditional use permits issued by the appropriate city or county, if applicable.
DTSC 1428 (07/10/2019)
page 1 of 2
Print
Clear
State of California – California Environmental Agency
Department of Toxics Substances Control
rol
Certified Appliance Recycler Application
Please submit to:
Department of Toxic Substances Control
Attn: HWMP - CAR Application
1001 “I” Street, 11
th
Floor
P.O. Box 806
Sacramento, California 95812-0806
or
CAR@dtsc.ca.gov
Before you may remove “materials that require special handling” (MRSH) from a major appliance, you must be
approved as a Certified Appliance Recycler (CAR), pursuant to Health and Safety Code section 25211 et seq.
(AB 1447, 2007). You must also provide evidence of your CAR status to scrap metal facility.
Once a certificate is issued, DTSC will notify the certified uniform program agency (CUPA) in your jurisdiction
responsible for inspecting the certified appliance recycling facility.
Certificates issued will be valid for three years. Once your certification has expired, you are no longer a CAR
In order to continue operating as a CAR, you must renew your certification before the expiration date.
Please note: Any changes to the information provided on the Certified Appliance Recycler Application must be
submitted to DTSC in order for the certification to be valid.
Renewal CAR Number:
New CAR Number:
Please note: Entire application must be completed.
1. Business Information
Business name under which the applicant operates:
Physical Address:
Mailing Address:
Business Phone Number:
Business Owner Name:
Owner Address:
Owner Phone Number:
Email Address (if available):
2. Hazardous Waste Generator Identification Number:
3. Have filed for a storm water permit?
Yes
or
Not required to obtain
4. Have filed a hazardous materials business plan?
Yes
or
Not required to file
5. Tax identification number, assigned by the Franchise Tax Board:
6. Attach a copy of a business license.
7. Attach a copy of conditional use permits issued by the appropriate city or county, if applicable.
DTSC 1428 (07/10/2019)
page 1 of 2
State of California – California Environmental Agency
Department of Toxics Substances Control
8. Include a separate document with your application that describes your ability to properly remove and manage all
materials that require special handling (MRSH), including but not limited to a technical description of how each
MRSH will be removed and how each MRSH will be managed by applicant consistent with applicable laws. You
may also include any additional information that describes how you are capable of properly remove and manage
MRSH.
The list below are some areas of information that can be used to describe your ability to properly remove and
manage MRSH.
▪ General Knowledge - Types of MRSH found in appliances at your facility.
▪ Training - Training provided to personnel responsible for removing MRSH from appliances at your facility; by
whom; and contents covered in the training. Timing and frequency of training given/received for new and
current staff. Training methods (in person, online, etc.) and reference materials made available to staff (hard
copy, electronic, etc.).
▪ Health and Safety - Describe your facility’s health and safety plan and/or the duties of a safety officer, personal
protective equipment is used during the removal of MRSH; and spill kits information available at your facility.
▪ Proposed removal processes - Tools and equipment used to remove each type MRSH; how each MRSH is
identified; and the procedure used to remove each type of MRSH from the appliance.
▪ Storage
1
- Accumulation time of removed MRSH at your facility; containment of the MRSH; container labeling;
containers packed to avoid breakage; and your record-keeping system.
▪ Disposition of Waste - The disposition of each MRSH. The name(s) of the company(s) that picks up MRSH;
where the MRSH is sent and/or how it gets there.
DTSC will review your full application for completeness. If your application meets the requirements of the Health and
Safety Code section 25211.4 (a), DTSC will issue a numbered certificate. DTSC will notify applicants whose application
fails to meet the requirements for certification and the reason why.
Optional: Site Information:
Facility operations:
Days of the week:
Hours:
Open to the public?
Yes
No
Type, expected source, expected number or weight of appliances to be handled per month at your facility:
CERTIFICATION
CERTIFICATION
I certify under penalty of perjury that this document and all attachments were prepared under
my direction or supervision to assure that qualified personnel properly gathered and evaluated
the information submitted. Based on my inquiry of the person or persons directly responsible
for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate and complete.
Signature:
Date:
Printed Name:
Title:
1
Any MRSH that is a hazardous waste must be managed in accordance with California Code of Regulations, title 22, chapter 12.
DTSC 1428 (07/9/2019)
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