"Hazardous Waste Generator Certification of Facility Closure" - Vermont

Hazardous Waste Generator Certification of Facility Closure is a legal document that was released by the Vermont Department of Environmental Conservation - a government authority operating within Vermont.

Form Details:

  • The latest edition currently provided by the Vermont Department of Environmental Conservation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Vermont Department of Environmental Conservation.

ADVERTISEMENT
ADVERTISEMENT

Download "Hazardous Waste Generator Certification of Facility Closure" - Vermont

982 times
Rate (4.6 / 5) 59 votes
Shaded box for VT DEC Office Use Only
Date Received:________________
HAZARDOUS WASTE GENERATOR
Date Completed:_____________
CERTIFICATION OF FACLITY CLOSURE
Please return completed form to:
_____Pre-closure notification form filed
_____RCRA Info Completed
Waste Management & Prevention Division
One National Life Drive, Davis 1
Montpelier, Vermont 05620-3704
(802)828-1138
www.anr.state.vt.us/dec/wastediv/rcra/rcrahome.htm
Check One:
Complete Closure:
Continued Use Closure:
Site EPA ID:__________________________
Site Name:__________________________________________________
Business Owner/Operator:
Legal Property Owner:
Physical Address (not P.O. Box):
Street or P.O. Box:
City or Town/: Zip Code:
City:
State/ Zip Code:
Listing of Contaminants of Concern:
Conditional Exemption
MSDS Available
Hazardous Materials Used
Hazardous Waste Produced
Y/N
Used? Y/N:
Sweep
Cleanout Activities Completed: (Check all applicable items)
Power Wash
Hazardous materials removed
Copy of test results attached
Hazardous waste removed
The property has (or had) septic tank/system
Other
Date of Final Hazardous Waste Shipment:________________
Manifest No:_______________________
Certification:
I certify that the site identified above has been closed in accordance with the provisions of Vermont Hazardous Waste
Management Regulations 7-309(c)(1).
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 manage the 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 may be significant penalties of submitting false information, including the possibility for fine and imprisonment for
knowing violations.
Signature: ______________________________________________
Date: ________________________________
Name: __________________________________________________
Title: ___________________________________
Shaded box for VT DEC Office Use Only
Date Received:________________
HAZARDOUS WASTE GENERATOR
Date Completed:_____________
CERTIFICATION OF FACLITY CLOSURE
Please return completed form to:
_____Pre-closure notification form filed
_____RCRA Info Completed
Waste Management & Prevention Division
One National Life Drive, Davis 1
Montpelier, Vermont 05620-3704
(802)828-1138
www.anr.state.vt.us/dec/wastediv/rcra/rcrahome.htm
Check One:
Complete Closure:
Continued Use Closure:
Site EPA ID:__________________________
Site Name:__________________________________________________
Business Owner/Operator:
Legal Property Owner:
Physical Address (not P.O. Box):
Street or P.O. Box:
City or Town/: Zip Code:
City:
State/ Zip Code:
Listing of Contaminants of Concern:
Conditional Exemption
MSDS Available
Hazardous Materials Used
Hazardous Waste Produced
Y/N
Used? Y/N:
Sweep
Cleanout Activities Completed: (Check all applicable items)
Power Wash
Hazardous materials removed
Copy of test results attached
Hazardous waste removed
The property has (or had) septic tank/system
Other
Date of Final Hazardous Waste Shipment:________________
Manifest No:_______________________
Certification:
I certify that the site identified above has been closed in accordance with the provisions of Vermont Hazardous Waste
Management Regulations 7-309(c)(1).
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 manage the 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 may be significant penalties of submitting false information, including the possibility for fine and imprisonment for
knowing violations.
Signature: ______________________________________________
Date: ________________________________
Name: __________________________________________________
Title: ___________________________________