Form SFN19269 "Application for a Solid Waste Management Facility Permit" - North Dakota

What Is Form SFN19269?

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

Form Details:

  • Released on April 1, 2010;
  • The latest edition provided by the North Dakota Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form SFN19269 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN19269 "Application for a Solid Waste Management Facility Permit" - North Dakota

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APPLICATION FOR A SOLID WASTE MANAGEMENT FACILITY PERMIT
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT
Clear Fields
SFN 19269 (4-2010)
1. GENERAL INFORMATION
Facility Name
Permit Number
Application Date
Telephone Number
Physical Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Section
Township
Range
County
Geographic
Location
Latitude and Longitude (degrees, minutes, and seconds)
ID Number Assigned to Organization by the ND Secretary of State State under which your organization is organized
Is registration with the Secretary of
State required?
No
Yes
(701) 328-4284
2. FACILITY TYPE
Application for What Type of Facility
Inert Waste Landfill
Surface Impoundment
Transfer Station
Waste Pile (for example, tire piles
more than 800 tires; yard waste
Municipal Waste Landfill
Land Treatment Facility
Putrescible Waste
compost piles serving more than
Industrial Waste Landfill
Solid Waste Processing
Other Waste:
10,000 people)
Special Waste Landfill
Treatment or Resource Recovery Facilities
Other (Specify)
3. APPLICANT INFORMATION
Name of Applicant
Telephone Number
Fax Number
Address
City
State
Zip Code
Is Applicant a Political Subdivision?
If the applicant is not a political subdivision in the state of North Dakota, please enclose
appropriate information to describe any sole ownership, partnership, corporation, etc. Please
No
Yes
include a description of the major stockholders of any corporate entity, the membership of the
Is Applicant a Private Entity, Partnership, Corporation, etc.?
board of directors, a copy of the articles of incorporation, and any other information necessary
to describe the legal status of the applicant. Is this information enclosed?
No
Yes
No
Yes
4. Surveyed Land Description: The applicant must provide a formal surveyed description of the proposed facility signed by a Registered Land Surveyor in
the state of North Dakota and formally identify the facility boundaries. The applicant must demonstrate that he either owns the property and has legal access to
it or show that he has a formal lease or rental agreement signed by the property owner showing approval and access to use the site as a solid waste facility.
Is Survey Description of Property Attached?
Name of Property Owner
Telephone Number
No
Yes
Address
City
State
Zip Code
Is a Certified Copy of the Deed Showing Property
If the property is not owned by the operator, is a copy of the lease, rental agreement, or other
Ownership Enclosed?
documentation signed by the property owner showing approval to use
No
Yes
No
Yes
the site as a solid waste facility enclosed?
5. Easements or Encumbrances: A description of any easements around the property must be provided. This would include a description and a copy of any
above ground or underground pipeline or transmission line easements, right-of-way easements, wetland easements, etc. The location of all such facilities and
easements must be clearly identified on appropriate maps and legal descriptions attached to this application.
Does the applicant have clear and unencumbered access to the property to
Is information on any easements or access stipulations enclosed with this
be used as a solid waste management facility?
application?
No
Yes
No
Yes
Total acreage of proposed site
Acreage usable for solid waste management activities as described in plans
6. General Site Information: To help the Department assess the suitability of the facility, general site information and maps must be provided with the
application. At a minimum, the following information with the proposed facilities clearly defined should be enclosed with the application.
Topographic map of the area (USGS) Map depicting area drainage and surface
Aerial photographs of the site
County road map of the area
water flow patterns
No
No
Yes
Yes
No
Yes
No
Yes
Land ownership map of the area
Other Information
(county atlas)
No
Yes
APPLICATION FOR A SOLID WASTE MANAGEMENT FACILITY PERMIT
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT
Clear Fields
SFN 19269 (4-2010)
1. GENERAL INFORMATION
Facility Name
Permit Number
Application Date
Telephone Number
Physical Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Section
Township
Range
County
Geographic
Location
Latitude and Longitude (degrees, minutes, and seconds)
ID Number Assigned to Organization by the ND Secretary of State State under which your organization is organized
Is registration with the Secretary of
State required?
No
Yes
(701) 328-4284
2. FACILITY TYPE
Application for What Type of Facility
Inert Waste Landfill
Surface Impoundment
Transfer Station
Waste Pile (for example, tire piles
more than 800 tires; yard waste
Municipal Waste Landfill
Land Treatment Facility
Putrescible Waste
compost piles serving more than
Industrial Waste Landfill
Solid Waste Processing
Other Waste:
10,000 people)
Special Waste Landfill
Treatment or Resource Recovery Facilities
Other (Specify)
3. APPLICANT INFORMATION
Name of Applicant
Telephone Number
Fax Number
Address
City
State
Zip Code
Is Applicant a Political Subdivision?
If the applicant is not a political subdivision in the state of North Dakota, please enclose
appropriate information to describe any sole ownership, partnership, corporation, etc. Please
No
Yes
include a description of the major stockholders of any corporate entity, the membership of the
Is Applicant a Private Entity, Partnership, Corporation, etc.?
board of directors, a copy of the articles of incorporation, and any other information necessary
to describe the legal status of the applicant. Is this information enclosed?
No
Yes
No
Yes
4. Surveyed Land Description: The applicant must provide a formal surveyed description of the proposed facility signed by a Registered Land Surveyor in
the state of North Dakota and formally identify the facility boundaries. The applicant must demonstrate that he either owns the property and has legal access to
it or show that he has a formal lease or rental agreement signed by the property owner showing approval and access to use the site as a solid waste facility.
Is Survey Description of Property Attached?
Name of Property Owner
Telephone Number
No
Yes
Address
City
State
Zip Code
Is a Certified Copy of the Deed Showing Property
If the property is not owned by the operator, is a copy of the lease, rental agreement, or other
Ownership Enclosed?
documentation signed by the property owner showing approval to use
No
Yes
No
Yes
the site as a solid waste facility enclosed?
5. Easements or Encumbrances: A description of any easements around the property must be provided. This would include a description and a copy of any
above ground or underground pipeline or transmission line easements, right-of-way easements, wetland easements, etc. The location of all such facilities and
easements must be clearly identified on appropriate maps and legal descriptions attached to this application.
Does the applicant have clear and unencumbered access to the property to
Is information on any easements or access stipulations enclosed with this
be used as a solid waste management facility?
application?
No
Yes
No
Yes
Total acreage of proposed site
Acreage usable for solid waste management activities as described in plans
6. General Site Information: To help the Department assess the suitability of the facility, general site information and maps must be provided with the
application. At a minimum, the following information with the proposed facilities clearly defined should be enclosed with the application.
Topographic map of the area (USGS) Map depicting area drainage and surface
Aerial photographs of the site
County road map of the area
water flow patterns
No
No
Yes
Yes
No
Yes
No
Yes
Land ownership map of the area
Other Information
(county atlas)
No
Yes
SFN 19269 (4-2010)
Page 2 of 4
7. Preapplication: For new or lateral expansion of land treatment units, surface impoundments closed with waste in place, municipal waste landfills,
industrial waste landfills, and special waste landfills, has a preapplication assessment of the proposed site been approved?
No
Yes
8. Facility Access and Hauling: Please enclose any maps and supporting narrative identifying the suitability and adequacy of roads and bridges used as
access routes to support loaded vehicles. Also indicate the modes of transportation and the waste haulers. Is this information enclosed?
No
Yes
9. Compliance History: Please enclose an accurate description of the compliance history of the permit applicant. Include any identified violations of the
North Dakota Solid Waste Management Rules and/or any violations of state or federal rules at any other facilities or through any activities
No
Yes
engaged in by the applicant. Is this information enclosed?
10. Waste Information: The application must include a description of the nature and quantity of materials or wastes proposed to be handled, processed,
stored, or disposed during the period of the permit along with an identification of the generators (industries, businesses, municipalities, individuals, and
populations) to be served by the proposed facility. As necessary, waste characterization and waste acceptance information must be provided.
11. Disposal, Recycling, Treatment, or Resource Recovery: For a transfer station, solid waste processing, treatment, or resource recovery facility, or a
waste pile, the applicant must identify the end use, the location and/or the facility to which the waste will eventually be transferred. The applicant must
demonstrate that all solid waste, recycled material, residues, and leachate will be managed at a state approved/permitted solid waste facility or at a facility that
is in compliance with the regulations of the state, tribal, or federal agency having jurisdiction. Is this information enclosed?
No
Yes
12. Compliance with Rules: Permit applicants must include all appropriate information necessary to show how the facility will be in compliance with all state
and federal rules and regulations. Appropriate sections of the North Dakota Solid Waste Management Rules that must be addressed include, but are not
necessarily limited to, the following:
Chapter 33-20-01.1 General Provisions. Is this information enclosed?
Chapter 33-20-02.1 Permit Provisions and Procedures. Is this information
enclosed?
No
Yes
No
Yes
Chapter 33-20-03.1 Permit Application
Date the affidavit from the official county newspaper will be submitted to the Department certifying that the two
Provisions. Is this
public notices have been published (see subsection 4, Section 33-20-03.1-02 NDAC).
No
Yes
information enclosed?
Chapter 33-20-04.1 General Performance Standards. Is this information enclosed?
No
Yes
Specific facility standards appropriate for the type of facility operation including the following (check those that apply):
Chapter 33-20-05.1 Inert Waste Landfills.
Chapter 33-20-06.1 Municipal Waste Landfills.
Chapter 33-20-07.1 Industrial Waste Landfills.
Chapter 33-20-08.1 Surface Impoundments.
Chapter 33-20-09 Landfills Treatment Provisions.
Section 33-20-04.1-06 Transfer Stations, Baling and Compaction Systems, Processing Systems, and Drop Box Facilities.
Section 33-20-04.1-07 Piles Used for Storage and Treatment Standards.
Section 33-20-04.1-08 Solid Waste Treatment or Resource Recovery Facilities.
Please refer to the Department's "Quality Assurance Guidelines" for information to be obtained for construction quality assurance and reporting for appropriate
facilities. Other guidance information may be available for certain facilities.
13. Water Protection: The facility must demonstrate compliance with the General Location Standards of Section 33-20-04.1-01 NDAC and the Water
Protection Provisions of Chapter 33-20-13. Please refer to the Department's "Guidelines for Hydrogeologic Investigations of Solid Waste Facilities" and
"Guidelines for Corrective Action of Solid Waste Facilities" for additional information and guidance. Is the information to demonstrate
No
Yes
compliance enclosed?
14. Storm Water Compliance: The facility should demonstrate the ability to properly manage storm water and must demonstrate compliance with the
NDPDES storm water permit program. A completed application for an industrial and/or construction permit should be filed for approval thirty (30) days prior to
the start of operation. Please refer to the enclosed fact sheet for more information. Has an application been filed?
No
Yes
If no, Specify When an Application Will Be Filed
Is storm water management addressed in the solid waste application?
No
Yes
15. Personnel: Enclose a narrative describing the duties, experience, and training of operators and other personnel for the facility. For municipal waste
landfills, demonstrate how the facility will be in compliance with the requirements for certification of operators, Chapter 33-20-16 NDAC. Is the information
enclosed?
No
Yes
16. Life of Facility: Describe the estimated life of the facility and attach a description of the method used to calculate this figure. Is the description attached?
Estimated Life
No
Yes
17. Site Development: Please enclose a timetable showing the proposed site development schedule for the facility and showing timelines for completing the
activities proposed in the permit application. Is the information enclosed?
No
Yes
Proposed Opening Date of Facility
Proposed Closing Date of Facility
SFN 19269 (4-2010)
Page 3 of 4
18. Insurance: Provide the name and address of the insurer of the facility and/or attach a copy of the general liability insurance policy. Provide a statement
regarding the limits of the policy for sudden and nonsudden liability coverage. Is a statement of coverage attached?
No
Yes
Name of Insurer
Telephone Number
Address
City
State
Zip Code
19. Financial Assurance: Please demonstrate how the facility will comply with the financial assurance requirements of Chapter 33-20-14 NDAC. Is the
information enclosed?
No
Yes
20. Local Zoning: Does the site meet the requirements of any local zoning jurisdiction in the area of the facility (county, township, city,
No
Yes
etc.)?
Please enclose a copy of any pertinent local zoning ordinances, maps, and a statement from the local zoning authorities and/or political subdivisions that the
use of the property for a solid waste management facility as described in this application is consistent with local zoning and/or permitting ordinances. Please
enclose a copy of any required local permits. Is this information enclosed?
No
Yes
21. Are local health officials knowledgeable of the facility and the practices to be employed at the site?
No
Yes
22. Fees: Depending on the type and size of the facility, enclose an appropriate application processing fee and annual permit fee as identified in Chapter 33-
20-15. Are the appropriate fees attached?
No
Yes
23. Other Permits: Will any other structures or features be constructed at the site that require any other permits (for example, underground tanks, air
pollution sources, etc.)? If yes, please enclose information to show such facilities will be in compliance with state or federal regulations.
No
Yes
24. Signatures: A permit application must be signed as follows:
a.
For a corporation, by a principal executive officer of at least the level of vice-president or the duly authorized representative or agent of the executive
officer if the representative or agent is responsible for the overall operation of the facility that is the subject of the permit application;
b.
For a partnership or sole proprietorship, by a general partner or the proprietor, respectively;
c.
For a municipality, state, federal, or other public agency, by either a principal executive officer or ranking elected official;
d.
If the operator of the facility for which the application is submitted is different from the owner, by both the owner and the operator according to Items A
to C;
e.
For solid waste management facilities, by the facility owner and landowner under Items A to C if the landowner is different from the owner of the facility
for which the application is submitted; and
f.
For a firm preparing the necessary reports and plans for a solid waste management facility permit application, by an engineer registered in North
Dakota.
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who will
manage this system or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information.
Owner's Signature
Date Signed
Print Name
Official Title
Operator's Signature
Date Signed
Print Name
Official Title
Landowner's Signature
Date Signed
Print Name
Official Title
Engineer's Signature
Date Signed
Print Name
Registration
Return this form (and application fee if applicable) to:
North Dakota Department of Health
Division of Waste Management
918 E Divide Ave., 3rd Fl.
Bismarck, ND 58501-1947
SFN 19269 (4-2010)
Page 4 of 4
General Information
Form SFN-19269 Application for A Solid Waste Management Facility Permit
Attached is application form, SFN 19269, for a North Dakota Solid Waste Management Facility Permit. This
application form, along with the appropriate attachments, must be completed in order to obtain a permit
pursuant to Chapter 23-29 of the North Dakota Century Code (NDCC) and Article 33-20 of the North Dakota
Administrative Code (NDAC). For your convenience, the application form and rules are also found on the
Departments website at www.ndhealth.gov/wm. Applicants should obtain a copy of these rules and related
guidelines and be knowledgeable of the requirements prior to completing the application. Any permit issued by
the Department will be based on the permit application information.
Please be sure that you address all information required on the form as well as all other information required
under the Solid Waste Management Rules. Return this completed form along with the attachments and other
information necessary to complete an application. In certain cases the Department may already have on file
information from previous permits or facility evaluations. If the Department deems this material adequate, the
applicant may reference these documents, the date they were submitted, and the date they were approved. In
the event an application is not considered complete, or is inaccurate or deficient as outlined in the North Dakota
Solid Waste Management Rules and Departmental guidelines, the Department will notify the applicant as
promptly as possible so that the applicant has the opportunity to revise the submittal.
Permit preapplication provisions are identified in Section 33-20-03.1 of the North Dakota Solid Waste
Management Rules. All applications for new solid waste management facilities must comply with the
preapplication procedures. Submittal of an application for a new or modified permit requires the applicant to
publish a Public Notice as specified in Section 33-20-03.1-02 NDAC. Department permit application review and
action procedures are contained in Section 33-20-03.1-03 NDAC. This section also indicates which public
participation processes are appropriate for new or modified applications. The Department consults with the
North Dakota Geological Survey, the North Dakota State Water Commission, the Department's Division of
Water Quality, and any other agencies necessary to help assess a site's suitability. Thus, a minimum of four
copies of application materials is required. Additional copies may be necessary for other affected state or
federal agencies and any local political subdivisions, etc.
A permit from the Department does not supersede local zoning authority or any other requirements of any
political subdivision of the state. Coordination with any local zoning officials, local health officials, and any other
necessary local, state or federal programs and agencies are necessary prior to submitting the application.
Corroboration of such information is necessary to proceed with the application review. The Department
encourages all applicants to work closely with local political subdivisions and local health officials, as well as the
Department, throughout the permitting process.
For questions, please contact the Division of Waste Management at (701) 328-5166.
For questions regarding securing of registration numbers from the ND Secretary of States Office, call (701) 328-
4284.
Page of 4