Form DEEP-RCY-REG-007 "General Permit Registration Form to Perform One Day Collections of Certain Wastes and Household Hazardous Waste" - Connecticut

Form DEEP-RCY-REG-007 Printable Pdf
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What Is Form DEEP-RCY-REG-007?

This is a legal form that was released by the Connecticut Department of Energy and Environmental Protection - a government authority operating within Connecticut. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on October 14, 2014;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DEEP-RCY-REG-007 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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Download Form DEEP-RCY-REG-007 "General Permit Registration Form to Perform One Day Collections of Certain Wastes and Household Hazardous Waste" - Connecticut

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CPPU USE ONLY
General Permit Registration Form
to Perform One Day Collections of
App #:________________________________
Certain Wastes and Household
Doc #:________________________________
Hazardous Waste
Check #:______________________________
______________________________________
Please complete this form in accordance with the
instructions
(DEEP-
RCY-INST-007) to ensure the proper handling of your registration. Print or
Program: Transfer Station General Permit
type unless otherwise noted. You must submit the registration fee along
with this form.
Part I: Registration Type
Check the appropriate box identifying the registration type.
This registration is for (check one):
Identify any existing permit or registration approval
already issued:
A new registration
Permit or registration number:
A renewal of an existing registration
Date granted:
A modification of an existing registration
Town where site is located:
Brief Description of Project:
Part II: Fee Information
A fee of two thousand five hundred ($2,500)
dollars is to be submitted with each registration that you are
[#1404]
submitting. The registration will not be processed without the fee.
The fee is non-refundable and shall be paid by check or money order to the: Department of Energy and
Environmental Protection. For municipalities, a fifty percent (50%) discount of the registration fee applies.
DEEP-RCY-REG-007
Page 1 of 4
Rev. 10/14/14
CPPU USE ONLY
General Permit Registration Form
to Perform One Day Collections of
App #:________________________________
Certain Wastes and Household
Doc #:________________________________
Hazardous Waste
Check #:______________________________
______________________________________
Please complete this form in accordance with the
instructions
(DEEP-
RCY-INST-007) to ensure the proper handling of your registration. Print or
Program: Transfer Station General Permit
type unless otherwise noted. You must submit the registration fee along
with this form.
Part I: Registration Type
Check the appropriate box identifying the registration type.
This registration is for (check one):
Identify any existing permit or registration approval
already issued:
A new registration
Permit or registration number:
A renewal of an existing registration
Date granted:
A modification of an existing registration
Town where site is located:
Brief Description of Project:
Part II: Fee Information
A fee of two thousand five hundred ($2,500)
dollars is to be submitted with each registration that you are
[#1404]
submitting. The registration will not be processed without the fee.
The fee is non-refundable and shall be paid by check or money order to the: Department of Energy and
Environmental Protection. For municipalities, a fifty percent (50%) discount of the registration fee applies.
DEEP-RCY-REG-007
Page 1 of 4
Rev. 10/14/14
Part III: Registrant Information
If a registrant is a corporation, limited liability company, limited partnership, limited liability partnership, or a
statutory trust, it must be registered with the Secretary of State. If applicable, registrant’s name shall be stated
exactly as it is registered with the Secretary of State. Please note, for those entities registered with the
Secretary of State, the registered name will be the name used by DEEP. This information can be accessed at
the Secretary of State's database (CONCORD). (www.concord-sots.ct.gov/CONCORD/index.jsp)
If a registrant is an individual, provide the legal name (include suffix) in the following format: First Name;
Middle Initial; Last Name; Suffix (Jr., Sr., II, III, etc.).
If there are any changes or corrections to your company/facility or individual mailing or billing address or
contact information, please complete and submit the
to the
Request to Change Company/Individual Information
address indicated on the form. If there is a change in name of the entity holding a DEEP license or a change in
ownership, contact the Office of Planning and Program Development (OPPD) at 860-424-3003. For any other
changes you must contact the specific program from which you hold a current DEEP license.
1. Registrant Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject registration. Please remember to check your security settings to be sure you can
receive e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
a) Registrant Type (check one):
individual
federal agency
state agency
municipality
tribal
*business entity (*If a business entity complete i through iii):
i)
check type:
corporation
limited liability company
limited partnership
limited liability partnership
statutory trust
Other:
ii) provide Secretary of the State business ID #:
This information can be accessed at
the Secretary of State's database (CONCORD). (www.concord-sots.ct.gov/CONCORD/index.jsp)
iii)
Check here if your business is NOT registered with the Secretary of State’s office.
Check here if any co-registrants. If so, attach additional sheet(s) with the required information as requested
above.
b) Registrant's interest in property at which the proposed activity is to be located:
site owner
option holder
lessee
easement holder
operator
other (specify):
DEEP-RCY-REG-007
Page 2 of 4
Rev. 10/14/14
Part III: Registrant Information (continued)
2. Billing contact, if different than the registrant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
3. Primary contact for departmental correspondence and inquiries, if different than the registrant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject registration. Please remember to check your security settings to be sure you can
receive e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
4. Transporter
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
5. Hazardous Waste Transporter Permit No.
6.
Biomedical Waste Transporter Permit No.
DEEP-RCY-REG-007
Page 3 of 4
Rev. 10/14/14
Part IV: Registrant Certification
Those individual(s) responsible for preparing this registration must sign below. This registration will be considered
incomplete unless all required signatures are provided. If the registrant/applicant is the preparer, mark N/A in the
spaces provided for the preparer.
“I have personally examined and am familiar with the information submitted in this document and I certify that
based on reasonable investigation, including my inquiry of the individuals responsible for obtaining the
information, the submitted information is true, accurate and complete to the best of my knowledge and belief.
I understand that a false statement in the submitted information may be punishable as a criminal offense, in
accordance with section 22a-6 of the General Statutes, pursuant to section 53a-157b of the General Statutes,
and in accordance with any other applicable statute.
I certify that this general permit registration is on complete and accurate forms as prescribed by the
commissioner without alteration of the text.
I also certify that an Emergency Preparedness and Prevention and an Operation and Management Plan has
been prepared in accordance with the requirements in Section 5(a)(1) of the General Permit to Perform One
Day Collections of Certain Wastes and Household Hazardous Waste and is available at the site or upon
request by the commissioner.”
Signature of Registrant/Applicant
Date
Name of Registrant/Applicant (print or type)
Title (if applicable)
Signature of Preparer (if different than applicant)
Date
Name of Preparer (print or type)
Title (if applicable)
Check here if additional signatures are required. You must include signatures of any person preparing
any report or parts thereof required in this submittal (i.e., professional engineers, surveyors, soil
scientists, consultants, etc.)
If needed, reproduce this page and attach signed copies to this sheet.
Please submit:
(1) Completed Registration Form;
(2) One copy of the entire package; and
(3) Fee
To:
CENTRAL PERMIT PROCESSING UNIT
DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION
79 ELM STREET
HARTFORD, CT 06106-5127
DEEP-RCY-REG-007
Page 4 of 4
Rev. 10/14/14
Connecticut Department of Energy and Environmental Protection Connecticut Legal Forms United States Legal Forms

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