DTSC Form 1428 "Certified Appliance Recycler Application" - California

What Is Form DTSC1428?

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 30, 2014;
  • 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 printable version of Form DTSC1428 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
Linda S. Adams
Certified Appliance Recycler Application
Secretary for
Environmental Protection
Please submit to:
Department of Toxic Substances Control
Attn: Consumer Products Section- CAR application
1001 “I” Street, 11th 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, pursuant to Health and Safety Code Section 25211 et seq (AB 1447,
2007). You must also provide evidence of your CAR status to a scrap metal facility.
Once a certificate is issued, DTSC will notify the Certified Unified 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 Certified
Appliance Recycler. 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 for 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.) Is your organization required to obtain a storm water permit?
Yes
No
4.) Is your organization required to file a hazardous materials business plan?
Yes
No
5.) Tax identification number, assigned by the Franchise Tax Board:
6.) Attach a copy of a business license to this application.
7.) If applicable, attach a copy of conditional use permits issued by the appropriate city or county to this application.
DTSC 1428 (7/30/2014)
page 1 of 2
State of California – California Environmental Agency
Department of Toxics Substances Control
Linda S. Adams
Certified Appliance Recycler Application
Secretary for
Environmental Protection
Please submit to:
Department of Toxic Substances Control
Attn: Consumer Products Section- CAR application
1001 “I” Street, 11th 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, pursuant to Health and Safety Code Section 25211 et seq (AB 1447,
2007). You must also provide evidence of your CAR status to a scrap metal facility.
Once a certificate is issued, DTSC will notify the Certified Unified 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 Certified
Appliance Recycler. 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 for 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.) Is your organization required to obtain a storm water permit?
Yes
No
4.) Is your organization required to file a hazardous materials business plan?
Yes
No
5.) Tax identification number, assigned by the Franchise Tax Board:
6.) Attach a copy of a business license to this application.
7.) If applicable, attach a copy of conditional use permits issued by the appropriate city or county to this application.
DTSC 1428 (7/30/2014)
page 1 of 2
State of California – California Environmental Agency
Department of Toxics Substances Control
8.) In an attached document, describe in detail your ability to properly remove and manage all materials that require
special handling (MRSH) (HSC 25211.4(a)), found in appliances. The list below describes the level of detail that
DTSC would like to see:
General Knowledge- What types of MRSH are found in specific appliances?
Training- Who will provide training to personnel responsible for removing MRSH from appliances at your
facility? What are the contents of the training and what MRSH will be covered? How frequently will staff be
trained? When will new staff be trained? What hard copy and electronic training and reference materials will
be made available to staff?
Health and Safety- Describe your facility’s health and safety plan and/or the duties of a safety officer. What
personal protective equipment is used during the removal of MRSH? Provide information for spill kits
available at your facility.
Proposed removal processes- List the tools and equipment you use to remove each type MRSH. Briefly
describe how each MRSH is identified and the procedure used to remove each type of MRSH from the
appliance.
1
Storage
- How long do you plan to accumulate removed MRSH at your facility? Describe the containment of
the MRSH. How are the containers labeled for each MRSH? Describe how materials will be packaged to
avoid breakage. Describe your record-keeping system.
Disposition of Waste- What will be the disposition of each MRSH? Please provide the name of the
company that picks up waste, or a description of where the waste is sent and/or how it gets there.
What else should we know in order determine that you are capable of properly removing & managing MRSH?
Optional: Site Information:
Days and hours of operation of the facility:
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 Ch. 12 of 22 CCR
DTSC 1428 (7/30/2014)
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