TRANSPORTER QUALIFICATION REVIEW APPLICATION Prescribed by: DRMS I 4160.14 Sponsor: Disposition Services

Instructions: Please complete form electronically and save file using name of carrier.

1. Transporter Name: 2. Transporter 12 Digit I.D. Number (if applicable):

Instructions: Complete all sections and provide backup documentation 3. Transporter Address:

where requested. If the requested information is not applicable, please identify as N/A.

4. List primary waste transporter permit numbers:

Motor Carrier Safety (CONUS Only)

5. Federal Motor Carrier Safety Administration (FMCSA) USDOT Number: 6. FMCSA audit date:

7. List dates, city and state location of any Federal or State safety violations in the last 3 years:

8. Has the company had any traffic citations or hazardous materials incidents within the last three years?

Yes No

If yes, provide enforcement agency copies of traffic citations or hazardous materials incident report.

9. Provide current Office of Motor Carrier Safety (OMCS) or State DOT rating:

Risk Mitigation

10. Does company have a written hazardous materials safety training program?

Yes No

If yes, provide a copy of the training program.

11. Does company maintain general, property, bodily injury and pollution liability insurance coverage?

Yes No

If yes, provide copy of insurance certificates.

12. Are all loads transported by company owned/leased vehicles? Yes No

If no, all contractors must meet same criteria to qualify as a DLA approved transporter.

13. Will carrier be providing transportation services using marine vessels? Yes No

If question 13 was yes, carrier is required to submit International Maritime Dangerous Goods (IMDG) transportation licenses.

14. Will CONUS carrier be required to transport material outside the continental United States or is this an overseas transporter?

If yes to question 14, provide list of countries below and submit foreign country license documentation. Yes No

Company Representation

15. Name of representative completing application: Date:

16. Phone number and e-mail of primary contact person for transporter:

For DLA Use Only As the verifier, I certify that the information provided on this form is true and correct.

NAME OF DLA VERIFIER: VERIFIER SIGNATURE & DATE:

DLA FORM 2503, SEP 2016 PDF (DLA)