Form CalRecycle769 "Recycler/Processor Web Portal Access Request Form" - California

What Is Form CalRecycle769?

This is a legal form that was released by the California Department of Resources Recycling and Recovery - 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 March 1, 2016;
  • The latest edition provided by the California Department of Resources Recycling and Recovery;
  • 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 Form CalRecycle769 by clicking the link below or browse more documents and templates provided by the California Department of Resources Recycling and Recovery.

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Download Form CalRecycle769 "Recycler/Processor Web Portal Access Request Form" - California

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State of California, Department of Resources Recycling and Recovery
Division of Recycling Integrated Information Systems
Recycler/Processor Web Portal Access Request Form
_____________________________________________
(CalRecycle 769) (Rev. 3/16)
_____________________________________________
Section 1: Request
_____________________________________________
New
Reactivation
Deactivation
Modification of Email Address
_____________________________________________
Section 2: Authorized User Information
Employee First Name:
Employee Last Name:
___________________________________________ _____________________________________________
Company Name:
Employee Email
(must be unique for each employee)
___________________________________________ _____________________________________________
RC/PR #
Work Phone:
Cell Phone:
(required to retrieve the operator record associated with this request):
___________________________________________ ____________________ ________________________
_____________________________________________
Section 3: Access
Portal access will be granted for ALL certification numbers operated by your company. Your business will be granted DORIIS
responsibilities based on the types of certifications your business operates. The following responsibilities will be made available:
Recycling Center
Processor
Shipper
Receiver
Processor
_____________________________________________
Shipper-Daily Summary
Handling Fees
Receiver
_____________________________________________
Section 4: Declaration and Signatures
By signing and submitting this form, I certify that I have read, understand and accept the DORIIS Access Terms and
Conditions of Use (https://www.calrecycle.ca.gov/docs/cr/BevContainer/Forms/CalRecycle769TCs.pdf).
I declare under penalty of perjury under the laws of the State of California that all the information on this request form is true
and correct.
Authorized User:
Signed By
:____________________________
Printed Name/Title:
Date:
_________________
_________________________
By signing and submitting this form, I certify that I have read, understand and accept the DORIIS Access Terms and
Conditions of Use (https://www.calrecycle.ca.gov/docs/cr/BevContainer/Forms/CalRecycle769TCs.pdf).
As responsible party, I authorize this person to access the web portal account of the above-named entity and acknowledge
that I am responsible for all use of the DORIIS portal and electronic submission made by this person.
I declare under penalty of perjury under the laws of the State of California that all the information on this request form is true
and correct, that I represent the above-named entity and I am duly authorized to sign this request.
Responsible Party:
Signed By:_
___________________________
Printed Name/Title:
_____________________________________________
Date:
Email:
Phone Number:
___________
_________________________________________
________________
Mail Completed Form to:
Department of Resources Recycling and Recovery (CalRecycle), Division of Recycling Recycling Program
__________________________________________________
Certification and Registration Branch, 801 K Street, MS 15-59, Sacramento, CA 95814-3533
__________________________________________________
For State Use Only:
Site Reg ID:____________________________________ Responsible Party Verified:_______________________________________
Person Reg ID:__________________________________ Linked to Organizations:________________________________________
Op Reg ID:______________________________ RC:______________________________ PR:______________________________
___________________________________________________________________________________________________________
Clear
Print
State of California, Department of Resources Recycling and Recovery
Division of Recycling Integrated Information Systems
Recycler/Processor Web Portal Access Request Form
_____________________________________________
(CalRecycle 769) (Rev. 3/16)
_____________________________________________
Section 1: Request
_____________________________________________
New
Reactivation
Deactivation
Modification of Email Address
_____________________________________________
Section 2: Authorized User Information
Employee First Name:
Employee Last Name:
___________________________________________ _____________________________________________
Company Name:
Employee Email
(must be unique for each employee)
___________________________________________ _____________________________________________
RC/PR #
Work Phone:
Cell Phone:
(required to retrieve the operator record associated with this request):
___________________________________________ ____________________ ________________________
_____________________________________________
Section 3: Access
Portal access will be granted for ALL certification numbers operated by your company. Your business will be granted DORIIS
responsibilities based on the types of certifications your business operates. The following responsibilities will be made available:
Recycling Center
Processor
Shipper
Receiver
Processor
_____________________________________________
Shipper-Daily Summary
Handling Fees
Receiver
_____________________________________________
Section 4: Declaration and Signatures
By signing and submitting this form, I certify that I have read, understand and accept the DORIIS Access Terms and
Conditions of Use (https://www.calrecycle.ca.gov/docs/cr/BevContainer/Forms/CalRecycle769TCs.pdf).
I declare under penalty of perjury under the laws of the State of California that all the information on this request form is true
and correct.
Authorized User:
Signed By
:____________________________
Printed Name/Title:
Date:
_________________
_________________________
By signing and submitting this form, I certify that I have read, understand and accept the DORIIS Access Terms and
Conditions of Use (https://www.calrecycle.ca.gov/docs/cr/BevContainer/Forms/CalRecycle769TCs.pdf).
As responsible party, I authorize this person to access the web portal account of the above-named entity and acknowledge
that I am responsible for all use of the DORIIS portal and electronic submission made by this person.
I declare under penalty of perjury under the laws of the State of California that all the information on this request form is true
and correct, that I represent the above-named entity and I am duly authorized to sign this request.
Responsible Party:
Signed By:_
___________________________
Printed Name/Title:
_____________________________________________
Date:
Email:
Phone Number:
___________
_________________________________________
________________
Mail Completed Form to:
Department of Resources Recycling and Recovery (CalRecycle), Division of Recycling Recycling Program
__________________________________________________
Certification and Registration Branch, 801 K Street, MS 15-59, Sacramento, CA 95814-3533
__________________________________________________
For State Use Only:
Site Reg ID:____________________________________ Responsible Party Verified:_______________________________________
Person Reg ID:__________________________________ Linked to Organizations:________________________________________
Op Reg ID:______________________________ RC:______________________________ PR:______________________________
___________________________________________________________________________________________________________
Recycler/Processor Web Portal Access Request Form
_____________________________________________
(CalRecycle 769) (Rev.3/16)
_____________________________________________
General Instructions for completing the Portal Access Request Form:
Please complete one form per employee you are requesting to have access to the DORIIS website.
A unique email address must be provided for each employee requesting access to the DORIIS website. Employees may not
share email accounts.
Form must be signed by both the Authorized User and the Responsible Party.
Make and retain a copy for your records.
Individuals may only have one active DORIIS user account
_____________________________________________
Access requested will be allowed for ALL certification numbers (sites) associated with this operator.
_____________________________________________
Section 1: Request Type
New: Check this box for entirely new accounts. This user has not had a DORIIS account before.
Reactivation: Check this box to reactivate an account that has been deactivated.
Deactivation: Check this box to remove access to DORIIS for this user.
_____________________________________________
Modification of Email Address: Check this box to change the email address for an existing, active DORIIS account.
_____________________________________________
Section 2: Authorized User Information
Name: Enter the last name and first name of the employee for whom you are requesting access.
Email Address: Enter the email address of the employee. This will become their username. This email must be unique for
each employee requesting access. Please write legibly.
RC/PR#: Enter the RC or PR number of the company. Enter only one number even if multiple Certification Numbers are
_____________________________________________
operated by the same company - this is for operator record retrieval only.
_____________________________________________
Section 4: Declaration and Signatures
Authorized User: Signature, printed name and date of the employee for whom this Portal Access Request Form is being
completed.
Responsible Party: Signature, printed name, title, email and contact phone number of certificate holder, registrant, officer,
director, managing employee, who is authorized by the certificate holder to sign this form.
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