Form CalRecycle778-GHG "Feedstock Certification" - California

What Is Form CalRecycle778-GHG?

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 August 1, 2018;
  • 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 CalRecycle778-GHG 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 CalRecycle778-GHG "Feedstock Certification" - California

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STATE OF CALIFORNIA
DEPARTMENT OF RESOURCES RECYCLING AND RECOVERY (CalRecycle)
FEEDSTOCK CERTIFICATION
CalRecycle 778-GHG (Rev. 8/18)
Instructions are located on the reverse side of this form. This Feedstock Certification form is a
required application, progress report, and performance payment request document. It is the
applicant/grantee’s responsibility to ensure the information provided by each primary feedstock
supplier (i.e., generator, processor, contractor, or hauler) is complete and accurate.
1. Applicant/Grantee Name:
2. Grant Number (if applicable):
3. Feedstock Verification
Application
Progress Report
Payment Request (Performance Payments Only)
4. Primary Feedstock Supplier (i.e., Generator, Processor, Contractor, or Hauler)
Primary Feedstock Supplier Name:
Contact Name:
Email:
Phone:
Fax:
Address:
Website:
City:
State:
Zip Code:
6. Secondary Feedstock
7. Quantity (tons) per
5. Feedstock Type (see reverse)
Supplier Name (If different
Week/Mo./Yr.
than #4 above)
(specify frequency)
TOTAL
The primary feedstock supplier agrees to the Audit/Records Access requirements found on the
reverse side of this form.
8. Primary Feedstock Supplier: Under the laws of California, I certify under penalty of perjury that I am
an authorized signatory for the above-named primary feedstock supplier and that the material provided to
the above-named applicant/grantee will originate only from California-generated waste that was
otherwise going to a landfill.
X
Signature (Primary Feedstock Supplier)
Date:
Print Name:
Title:
1
STATE OF CALIFORNIA
DEPARTMENT OF RESOURCES RECYCLING AND RECOVERY (CalRecycle)
FEEDSTOCK CERTIFICATION
CalRecycle 778-GHG (Rev. 8/18)
Instructions are located on the reverse side of this form. This Feedstock Certification form is a
required application, progress report, and performance payment request document. It is the
applicant/grantee’s responsibility to ensure the information provided by each primary feedstock
supplier (i.e., generator, processor, contractor, or hauler) is complete and accurate.
1. Applicant/Grantee Name:
2. Grant Number (if applicable):
3. Feedstock Verification
Application
Progress Report
Payment Request (Performance Payments Only)
4. Primary Feedstock Supplier (i.e., Generator, Processor, Contractor, or Hauler)
Primary Feedstock Supplier Name:
Contact Name:
Email:
Phone:
Fax:
Address:
Website:
City:
State:
Zip Code:
6. Secondary Feedstock
7. Quantity (tons) per
5. Feedstock Type (see reverse)
Supplier Name (If different
Week/Mo./Yr.
than #4 above)
(specify frequency)
TOTAL
The primary feedstock supplier agrees to the Audit/Records Access requirements found on the
reverse side of this form.
8. Primary Feedstock Supplier: Under the laws of California, I certify under penalty of perjury that I am
an authorized signatory for the above-named primary feedstock supplier and that the material provided to
the above-named applicant/grantee will originate only from California-generated waste that was
otherwise going to a landfill.
X
Signature (Primary Feedstock Supplier)
Date:
Print Name:
Title:
1
STATE OF CALIFORNIA
DEPARTMENT OF RESOURCES RECYCLING AND RECOVERY (CalRecycle)
FEEDSTOCK CERTIFICATION
CalRecycle 778-GHG (Rev. 8/18)
INSTRUCTIONS:
For the purpose of the application, the potential feedstock supplier(s) must validate that only California
generated material that was otherwise going to a landfill will be supplied for the proposed grant project. During
the grant term, each primary feedstock supplier who provided feedstock to the grant project must complete this
form. Retain a copy of this certification and all supporting documentation, which verifies the feedstock
supplied for the grant project is California-generated waste that was previously landfilled in California.
Item
Title
Applicant/Grantee Description
1.
Applicant or
Enter legal organization or business name as it appears in the application or
Grantee Name
Grant Agreement
2.
Grant Number (for
Grant Number that appears on the Grant Agreement
Grantee only)
3.
Feedstock
Check the appropriate box identifying if Feedstock Certification is being
Verification
submitted with the Application, Progress Report or Payment Request (for
Performance Payments only). Feedstock Certifications submitted during the
application are considered estimates and Feedstock Certifications submitted
with a Progress Report or Payment Request are considered actuals.
Item
Title
Processor, Contractor or Hauler Description
4.
Primary Feedstock
Provide the business contact information. Enter the contact name, address,
Supplier
city, state, zip, email, phone, fax, and website address.
5.
Feedstock Type
Enter the type of feedstock. Examples include:
 Residential commingled food and green materials
 Commercial pre- and/or post-consumer food materials
 Industrial food processing residuals
 Organic residuals separated from MSW
 Fiber (paper, textiles, carpet, or wood)
 Plastics (PET, HDPE, etc.)
 Glass
6.
Secondary
Enter the name(s) of any secondary feedstock suppliers. A secondary
Feedstock
feedstock supplier is someone who sends California-generated waste that was
Supplier Name
otherwise going to a landfill to the primary feedstock material supplier for
subsequent delivery to the applicant/grantee.
7.
Quantity
Enter the quantity in tons per week, month, or year. Specify frequency. If
Application, enter the estimated tons. If Progress Report or Payment Request
(for Performance Payments only), enter the actual tons.
8.
Signature
The Primary Feedstock Supplier must sign, date and print their name and title.
Audit/Records Access: The Primary Feedstock Supplier agrees that CalRecycle, the Department of Finance,
the Bureau of State Audits, or their designated representative(s) shall have the right to the review and to copy
any records and supporting documentation pertaining to this Certification of the products certified herein.
Additional supporting documentation may be requested by CalRecycle staff which includes but is not limited to:
Bill of Lading, weight tickets, shipping documents, Letter of Intent, Invoice, Contract, or other similar items. The
Primary Feedstock Supplier agrees to maintain such records for possible audit for a minimum of three (3)
years after final payment date or grant term end date, whichever is later, unless a longer period of records
retention is stipulated, or until completion of any action and resolution of all issues which may arise as a result
of any litigation, dispute, or audit, which is later. The Primary Feedstock Supplier agrees to allow the
designated representative(s) access to such records during normal business hours and to allow interviews of
any employees who might reasonably have information related to such records. Further, the Primary
Feedstock Supplier agrees to include a similar right of the state to audit records and interview staff of any
Secondary Feedstock Supplier and in any contract and subcontract related to this Certification of the products
certified herein. A Secondary Feedstock Supplier will be expected to provide supporting documentation if
subject to audit.
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