1240BE25Q0095 Attachment 6 Special Waste Disposal Application 2019.pdf

Special Waste Disposal Application 2014.docx Page 1 of 2

GENERATOR _______________________________________________________________________________________________

MAILING ADDRESS _____________________________________________ CITY _________________ ZIP__________________

CONTACT PERSON _____________________________________________ PHONE ________________ FAX ________________

SITE ADDRESS _________________________________________________ CITY __________________ ZIP _________________

CONSULTANT ______________________________________________________________________________________________

CONTACT PERSON _____________________________________________ PHONE ________________ FAX ________________

TRANSPORTER ____________________________________________________________________________________________

CONTACT PERSON _____________________________________________ PHONE ________________ FAX ________________

PAYMENT

All disposal fees must be paid by the hauler of the waste. We cannot bill the generator or consultant on behalf of the hauler.

PAYMENT METHOD Cash or check at time of disposal LANE COUNTY CHARGE ACCOUNT # ____________________

WASTE CHARACTERIZATION

Check one: □ Petroleum contaminated soil □ Industrial process waste □ Spill cleanup material □ Other

DESCRIPTION OF MATERIAL__________________________________________________________________________________

PROCESS GENERATING MATERIAL ___________________________________________________________________________

TONS PER DISPOSAL_________________ ANNUAL MONTHLY WEEKLY OTHER ____________________________

PERMIT REQUESTED FOR: ONE MONTH THREE MONTHS ONE YEAR OTHER ________________________

TOTAL TONNAGE PER PERMIT PERIOD ________________

HAS A HAZARDOUS WASTE DETERMINATION BEEN COMPLETED? YES NO

IS THE WASTE A HAZARDOUS WASTE AS DEFINED BY RCRA

OR BY THE STATE OF OREGON? YES NO

METHOD OF DETERMINATION: MSDS (ENCLOSE) TEST/ANALYTICAL RESULTS

KNOWLEDGE OF PROCESS OTHER ____________________________

PLEASE ENCLOSE ALL PERTINENT SUPPORTING DOCUMENTATION, INCLUDING ANY

AVAILABLE TEST RESULTS OR MSDS SHEETS. IF YOU ARE USING "KNOWLEDGE OF PROCESS",

PLEASE EXPLAIN IN A COVER LETTER. ADDITIONAL DOCUMENTATION MAY BE REQUIRED.

--- YOU MUST COMPLETE BOTH SIDES OF THIS PAGE ---

APPLICATION

SPECIAL WASTE DISPOSAL

FOR OFFICIAL USE

Permit No. SW 00___________

Expires: __________________

Waste Code:_______________

INSTRUCTIONS: Type, or print in ink. FILL OUT ALL APPLICABLE PORTIONS OF THIS FORM.

INCOMPLETE APPLICATIONS CANNOT BE PROCESSED. If more space is needed, attach separate page. The person responsible for accuracy of information must sign. Return application and any supporting documentation to the Waste Management Division with check for $25.00 non-refundable processing fee.

Additional testing or documentation may be required upon receipt of application. For waste which is required to be hauled separately from other waste, a landfill appointment is required before each disposal.

For disposal fees, cash or checks will be accepted, or a charge account may be established in advance (allow 2-3 weeks to establish new accounts; no disposal will be allowed until account is fully established).

To establish a charge account, call Waste Management Division Accounting at 682-6923.

ATTACHMENT 6

Special Waste Disposal Application 2014.docx Page 2 of 2

CERTIFICATION OF ACCURACY OF INFORMATION

I, __________________________________________, hereby certify under penalty of the laws of the State of Oregon that to the best of my knowledge the above-described waste is properly classified and identified and is not a RCRA or State of Oregon hazardous waste, and that the information given is true and complete. I have read the instructions on this application form and understand my responsibilities.

The generator of this waste has determined that the subject waste stream (as named above) IS NOT a hazardous waste by Oregon Department of Environmental Quality or US Environmental Protection Agency criteria (Ref: OAR 340-101 and 40 CFR Subparts B-D, Part 261). Specifically, the generator has determined that the waste is not "Flammable," "Corrosive," "Reactive," "Toxic," or "listed," as defined in the above-referenced regulations, and assumes all environmental liabilities if this waste is later determined to be a DEQ or EPA hazardous waste.

Signature_________________________________ Date ______________ Title __________________________________________

For those holders of Lane County charge accounts the $25.00 application fee maybe charge to account, or Enclose $25.00 application fee and MAIL TO:

INSTRUCTIONS AND DEFINITIONS

Special Waste: any waste material from a business, commercial or industrial source which, because of its origin, physical state or characteristics, would suggest that it may: be a hazardous waste, contain hazardous substances or wastes prohibited in municipal landfills, require additional management such as hazard review or special disposal conditions and/or precautions, carry potential liability to the Lane County landfill, or present health hazards to Lane County employees or to the public.

Unacceptable Waste: 1) Hazardous Waste and PCB waste as defined by Federal or State law and waste which is a threat to public health and the environment. 2) Waste prohibited from disposal at municipal sanitary landfills by State or Federal law, regulation, rule, code, permit, or permit condition. 3) Waste which in the judgment of the Waste Management Division will cause unreasonable operational problems, hazards, risks to landfill personnel or create unreasonable liability.

4) Liquid wastes, incinerator ash, tires, appliances, motor oil, lead acid batteries, and sealed drums and containers. Call for a list of all currently unacceptable wastes.

Application instructions:

1) The generator of the waste is required to determine whether or not the waste is hazardous prior to filling out the application. Lane County Waste Management Division cannot make this determination.

2) Fill in the application form completely. Incomplete or unsigned applications cannot be processed.

3) Enclose any additional information such as test results, MSDS sheets or other supporting documentation. If necessary, describe the waste completely in a cover letter.

4) Applications must be signed by the person who is responsible for the accuracy of the information given.

5) If the application is approved, an approved permit will be faxed and/or mailed to you. If the waste is required to be hauled separately from regular waste, it will be so noted on the permit. In this case, make a disposal appointment the day before you plan to dump by calling the fee booth (541) 726-3047. At the time of disposal at Short Mt. Landfill, show the scale booth attendant a copy of your permit. If the waste is allowed to be commingled with regular garbage, no appointment is needed, and you are not required to show the permit at the scale booth.

--DO NOT WRITE BELOW THIS LINE ---

WASTE MANAGEMENT DIVISION ACTION: Disposal of the above-described waste is: APPROVED DENIED

Signature _________________________________________________________________ Date _________________________

Special Instructions: Commingle with regular garbage Must be hauled separate from other waste

Lane County Waste Management Division, Attn. SPECIAL WASTE, 3100 E. 17th Ave., Eugene, OR 97403