DTSC Form 1171 "Collection Facility Notification for '"recycle-Only'" Household Hazardous Waste" - California

What Is Form DTSC1171?

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 October 1, 2007;
  • 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;

Download a fillable version of Form DTSC1171 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 1171 "Collection Facility Notification for '"recycle-Only'" Household Hazardous Waste" - California

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Department of Toxic Substances Control
State of California - California Environmental Protection Agency
COLLECTION FACILITY NOTIFICATION
FOR
“RECYCLE-ONLY” HOUSEHOLD HAZARDOUS WASTE
(check all the apply)
INITIAL NOTIFICATION
REVISED NOTIFICATION.
Place and asterisk in the
left margin next to the revised information
ONE TIME EVENT
CONTINUOUS OPERATIONS
1.
FACILTIY INFORMATION
A.
FACILITY NAME __________________________________________________________________________
B.
ADRESS _________________________________________________________________________________
C.
CITY ______________
STATE _____
ZIP CODE ________________________
D.
COUNTY___________________
FACILITY EPA ID NUMBER: ________________________
2.
FACILITY OPERATION INFORMATION
A.
DATE(S) FACILITY WILL OPERATE or BEGIN OPERATIONS ___________________________________
B.
CHECK DAY(S) OF OPERATION
M
T
W
TH
F
SAT
SUN
C.
HOURS OF COLLECTION___________________________________________________________________
D.
ADDITIONAL COLLECTION INFORMATION _________________________________________________
3.
CONTACT PERSON
A.
NAME _________________________________
B.
AGENCY _______________________________
PHONE NUMBER ___________________
4.
WASTE COLLECTED (CHECK ALL WASTES ACCEPTED AT THIS FACILITY)
Lead acid batteries
Small household batteries
Latex paint
Used oil
Used oil filters
Antifreeze
Intact spent Fluorescent lamps
Intact spent High Intensity Lamps
Universal Waste
I certify that the household hazardous waste collection facility listed above will be operated in accordance with Health
& Safety Code, Division 20, Article 10.8, Section 25218.8 and with any other requirements that may be imposed by the
California Department of Toxic Substances Control by regulation.
_________________________
_______________________________________________________________
Sponsoring Public Agency
Public Agency Address
_____________________________________________
_________________________
_______
Print Name and Title
Signature
Date
Submit original notification to your Certified Unified Program Agency (CUPA)
Mail copy to DTSC:
Department of Toxic Substances Control, Regulatory and Program Development
th
Division – HHW Unit, P.O. Box 806, 11
floor, Sacramento, California 95812-0806
DTSC Form 1171 (10/07)
Department of Toxic Substances Control
State of California - California Environmental Protection Agency
COLLECTION FACILITY NOTIFICATION
FOR
“RECYCLE-ONLY” HOUSEHOLD HAZARDOUS WASTE
(check all the apply)
INITIAL NOTIFICATION
REVISED NOTIFICATION.
Place and asterisk in the
left margin next to the revised information
ONE TIME EVENT
CONTINUOUS OPERATIONS
1.
FACILTIY INFORMATION
A.
FACILITY NAME __________________________________________________________________________
B.
ADRESS _________________________________________________________________________________
C.
CITY ______________
STATE _____
ZIP CODE ________________________
D.
COUNTY___________________
FACILITY EPA ID NUMBER: ________________________
2.
FACILITY OPERATION INFORMATION
A.
DATE(S) FACILITY WILL OPERATE or BEGIN OPERATIONS ___________________________________
B.
CHECK DAY(S) OF OPERATION
M
T
W
TH
F
SAT
SUN
C.
HOURS OF COLLECTION___________________________________________________________________
D.
ADDITIONAL COLLECTION INFORMATION _________________________________________________
3.
CONTACT PERSON
A.
NAME _________________________________
B.
AGENCY _______________________________
PHONE NUMBER ___________________
4.
WASTE COLLECTED (CHECK ALL WASTES ACCEPTED AT THIS FACILITY)
Lead acid batteries
Small household batteries
Latex paint
Used oil
Used oil filters
Antifreeze
Intact spent Fluorescent lamps
Intact spent High Intensity Lamps
Universal Waste
I certify that the household hazardous waste collection facility listed above will be operated in accordance with Health
& Safety Code, Division 20, Article 10.8, Section 25218.8 and with any other requirements that may be imposed by the
California Department of Toxic Substances Control by regulation.
_________________________
_______________________________________________________________
Sponsoring Public Agency
Public Agency Address
_____________________________________________
_________________________
_______
Print Name and Title
Signature
Date
Submit original notification to your Certified Unified Program Agency (CUPA)
Mail copy to DTSC:
Department of Toxic Substances Control, Regulatory and Program Development
th
Division – HHW Unit, P.O. Box 806, 11
floor, Sacramento, California 95812-0806
DTSC Form 1171 (10/07)