Att_4a._DL2507-1_Blank_QFL_Application_Form.pdf

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PDF (DLA)

DLA FORM 2507-1, MAR 2015

QUALIFIED FACILITY LIST APPLICATION

Prescribed by: DLAI 4160.14 Sponsor: Disposition Services Page of

IMPORTANT – READ FIRST

This application is for entities seeking to be placed on the DLA Disposition Services Qualified Facilities List (QFL) and is designed to be completed and submitted electronically. Provide all applicable information and supporting documents with this completed application. Make proper selections for the subject facility. Only companies currently under contract or that are bidding on a solicitation with DLA Disposition Services may request consideration for placement on the QFL. Approval will not be granted until all required documentation and regulatory compliance status have been received and verified. Some requested information is applicable only to facilities in the USA. Please refer to the last page of this application for detailed instructions.

SECTION 1 - PERMITTED TREATMENT AND PROCESS DESCRIPTION

Process Description Performed On-site Physical / Mechanical Subtitle C Landfill Subtitle D Landfill Lab Packing Battery Demanufacturing Electronics Demanufacturing Storage Bulking/Consolidation Gas Recovery Phase Separation/Filtration Deep Well Injection Fuels Blending Shredding/Separation Process Description Performed On-site Chemical Solidification Stabilization Paint Recycling/Re-use Neutralization Solvent Recovery/Reactivation Chemical Deactivation Carbon Adsorption Chemical Precipitation (WWT) Macro Encapsulation Micro Encapsulation Chemical Transformation Dechloriination Process Description Performed On-site Thermal Incineration Waste Fuels Kiln Solvent Recovery Thermal Desorption Smelting Waste to Energy Retort Other

SECTION 2 - MANAGEMENT METHODS AND CLIN TREATMENT / DISPOSAL CODES

Management Method Codes and Applicable Process Descriptions Waste CLIN Treatment / Disposal Requirement

SECTION 3 - REGULATORY AND FINANCIAL ASSURANCE

Submitted Applicant Comments Verification Comments DLA Use Only

1. According to the U.S. EPA Civil Enforcement Response Policy, have any RCRA Class One/ Two or other Significant Noncompliance (SNC) violations been issued to the facility? If yes, provide regulatory NOV documentation. (US Facilities Only)

2. Any administrative or judicial consent orders, corrective actions, or supplemental environmental projects in the last 3 years? If yes, provide documentation.

3. In the last 12 months has your facility caused a government generator to have to file a manifest exception report in accordance with 40 CFR 262.42(a)(2), or a state equivalent? (US Facilities Only)

4. Facility closure amount and financial mechanism (e.g., bond, trust, letter of credit). If closure instrument is not required by regulation, facility must satisfy item #5. Provide copy of actual financial instrument submitted to regulatory office.

5. Current certificates of accord showing pollution liability limits and other insurance coverage. If pollution liability insurance is not in place, facility must satisfy item #4. (Exception applies to non-hazardous facilities only).

6. Facility permit(s) cover page(s) recording expiration date.

7. Have any delays in returning signed manifests to the generator triggered exception reporting in the last year? (US Facilities Only)

8. Latest third party compliance inspection/report (Fed, State, Local, DLA) and documentation of corrective actions, no older than 18 months. See instructions.

9. Current facility environmental POC with phone number and e-mail address

10. Current environmental regulatory agency POC with phone number and email address.

APPLICANT INSTRUCTIONS

Official Facility Name Facility I.D. Number DLA Prime Contractor Name Contract Number Section One – Permitted Treatment and Process Description(s) Section Two – Management Method Codes and Waste CLIN Treatment/Disposal Codes Section Three – Regulatory and Financial Assurance Application Submitter Section 4 – Quality Assurance Verification Provide name of facility as it is assigned on any regulatory permits. Designate if using a dba. For all new applicants, this number can be an assigned EPA I.D. number if the facility is in the USA. If the facility does not have a US EPA I.D. enter "Need DSS Dummy Number". Provide the current DLA prime contractor's company name. Provide the contract number that the DLA prime contractor is working under for waste that would be shipped to the facility. Check all processes that are used to treat, store, recycle or dispose of material regardless if permits are required to be in place. For facilities regulated under United States laws, provide all management method codes or permitted waste codes used to treat, store, recover, or dispose of waste that correspond to the treatment processes designated in Section One. Management method codes can be found on the EPA web site in the Hazardous Waste Report Instructions and Forms booklet for the most current year: http://www.epa.gov/epawaste/inforesources/data/biennialreport/index.htm. Waste CLIN treatment and disposal codes can be found in the applicable DLA Disposition Services Contract. Many of the requirements in this section are designed for facilities located in the USA. If the facility is located outside the USA and the regulatory system does not support the requirement, please indicate so in the comments box. Do not leave a requirement unanswered and always provide the supporting documentation where requested. Not providing requested information and supporting documentation will only slow down the review process. Regular regulatory compliance auditing is defined as any multi-media audit by a third party acceptable to DLA or inspection by environmental regulatory enforcement official. Audit report must be provided and indicate completion within the last 18 months prior to submittal of QFL application. Print name and phone number of facility representative completing the application. Application will not be accepted without this information. Once form is complete submit it to the DLA Disposition Services by clicking on the "Submit Form" link at the top of form. Applicants should not complete Section 4. This section is for DLA use only.

9.0.0.2.20100902.2.720808 http://www.dla.mil/officialforms/files1/dl2507-1.pdf none

DL2507-1

Disposition Qualified Facility List Application Mar 2015