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State of New Jersey
Department of Environmental Protection
SOLID WASTE FACILITY PERMIT APPLICATION FORM
READ REQUIREMENTS - FOLLOW INSTRUCTIONS CAREFULLY - PLEASE PRINT OR TYPE
1a. Applicant/Owner*__________________ __________ Telephone
( )___________________
Permanent Legal Address
__________________________________________________________
City or Town __________________________State ____________Zip
Code___________________
Federal Tax I.D. or S.S.
#___________________________________________________________
1b. Applicant/Operator __________________________Telephone
( ) _____________________
Permanent Legal Address
____________________________________________________________
City or Town _________________________State ____________Zip
Code____________________
1c. Co-Permittee** ______________________________Telephone
( ) ______________________
Permanent Legal Address
____________________________________________________________
City or Town _________________________State ___________Zip
Code _____________________
FILE NO. ______________________________DATE RECEIVED __________________________
PROJECT MANAGER ____________________PROJECT ENGINEER ______________________
PERMIT TYPE __________________________TELEPHONE ( ) __________________________
FEES BILLED _________ DATE __________ DATE __________ DATE __________
RECEIVED _______ DATE __________ DATE __________ DATE __________
2. Location of Work _____________________________________________________________
Name of Facility, if applicable
_________________________________________________________
Address (Street/Road)
______________________________________________________________
Lot No.
_________________________________________________________________________
Block No.
_______________________________________________________________________
E.P.A. #
_________________________________________________________________________
Municipality ____________________________ County
____________________________________
3. Give name of: Engineer
Name _______________________________N.J. License No. _____________________________
Name of Firm
____________________________________________________________________
Address (Street/Road)
______________________________________________________________
City or Town ________________________State __________________Zip
Code_________________
Municipality
_____________________________________County_____________________________
Telephone ( ) ______________________
4. This is an application for
_____________________________________________________ Permit
(Name of permit, certification, approval, jurisdictional determination or
exemption.)
I. Application for: (Circle A. or B.)
A. New Facility
B. Existing Facility - Indicate (Expansion/Closure/Disruption___________________________________ ).
II. Facility Type:(Circle appropriate letters.) (Separate application for each)
| A. Sanitary Landfill B. Incinerator C. Compost D. Chemical Processing & Treatment Facility E. Transfer Station |
F. Shredder G. Baler H. Disruption I. Transfer Station/Material Recovery Facility X. Other |
III. Waste Type: (Circle all types of waste requested for acceptance at this facility by numbers.)
| 10. Municipal Waste (household, commercial and institutional) 12. Dry Sewage Sludge 13. Bulky Waste 23. Vegetative Waste 25. Animal and Food Processing Wastes 27. Dry Industrial |
72. Bulk Liquid and Semi-Liquid 73. Septic Tank Clean-Out Wastes 74. Liquid Sewage Sludge |
IV. Facility Life and Capacity:
| YEARS | TONS | CUBIC YARDS | |
| A. Proposed Facility Estimate | _______ | ______ | ______________ |
| B. Facility Expansion Estimate | _______ | _______ | ______________ |
V. Identification Numbers:
A. Facility Registration # ___________________________________________________________
B. Federal Employer ID # __________________________________________________________
C. Social Security # _______________________________________________________________
D. Certificate of Public Convenience & Necessity (CPCN) # _________________________________
Is (Will) this facility (be) under BPU regulation?
__________Yes __________ No
USE ADDITIONAL PAPER, IF REQUIRED, IN ORDER TO GIVE FULL AND COMPLETE DISCLOSURES TO THE FOLLOWING ITEMS.
VI. Type of Organization: (Circle appropriate letter.)
| A. Proprietorship | D. Municipal Government | G. Authority |
| B. Partnership | E. County Government | H. Federal Government |
| C. Corporation | F. State Government | X. Other |
VII. PARTNERSHIP DATA
A. State the name and address of each partner, including silent or limited,
and their interest:
| NAME | ADDRESS | PROPORTION OF INTEREST |
B. Registered in State of: ___________________________ County
of:______________________
C. Date of Filing:
________________________________________________________________
D. Agent's Name ________________________________________________________________ Street Address __________________________________ Telephone ( ) ______________________ City__________________________ State__________________ Zip Code ______________________
VIII. CORPORATE DATA:
A. Date of Incorporation
___________________________________________________________
B. Registered Agent (Name)
________________________________________________________
(Address)
____________________________________________________________
C. Corporate Officers:
OFFICIAL TITLE |
NAME |
BUSINESS ADDRESS |
D. Directors:
NAME OF DIRECTOR |
RESIDENCE |
TERM OF |
E. Identify below any individual, corporation or other business organization having ownership or a controlling interest in the applicant. If applicable, the chain of ownership or control should be traced to the main parent company.
NAME
___________________________________________________________________________
ADDRESS
________________________________________________________________________
NATURE OF CONTROL
____________________________________________________________
F. Principal Security Holders and Voting Power. Identify owner(s) of all securities in the applicant corporation having more than ten (10) percent of value.
| NAME | ADDRESS | TYPE OF SECURITIES* |
NUMBER OF VOTES |
*(Common stock, Preferred stock, etc.)
5. Other Permits Applied for or Obtained
APPLICATION
STATUS
| PERMIT TYPE (Use additional sheets if necessary) |
N.A. |
Pending | Approved | Date Applied for or Project Number |
| 5.1 CAFRA.................. | ||||
| 5.2 Waterfront Development........ | ||||
| 5.3 Tidal or Coastal Wetlands........... | ||||
| 5.4 Freshwater Wetlands Permit............. | ||||
| 5.5 Freshwater Wetlands Transitional Area Waiver (after July 1,1989).................. |
||||
| 5.6 Stream Encroachment.... | ||||
| 5.7 Water QualityCertificate (Section401)................... | ||||
| 5.8 Open Water Fill........ | ||||
| 5.9 Tidelands (Riparian) Grant, Lease or License................ | ||||
| 5.10 Divert Surface Waters for Private Use........ | ||||
| 5.11 Temporary Water Lowering............... | ||||
| 5.12 Sewer Systems: Collectors, Pump Station, etc.... | ||||
| 5.13 Underground Storage Tanks.................. | ||||
| 5.14 Hazardous Waste Permits (Specify)...... | ||||
| 5.15 Air Quality Permits.... | ||||
| 5.16 Delaware and Raritan Canal Review Zone "Certificate of Approval".............. | ||||
| 5.17 Pinelands Certificate............ | ||||
| 5.18 Green Acres Program Review................. | ||||
| 5.19 Other State Agencies' Permits...... | ||||
| 5.20 Federal Permits........ |
Brief Description of the Proposed Project and Intended Use:
6. Certification
I certify under penalty of law that I have personally examined and am familiar with the information submitted. in this document and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.
____________________________________
_________________________________
Type: Name and Date
Signature of Applicant/Owner
____________________________________
_________________________________
Type: Position Date
____________________________________
__________________________________
Type: Name and Date
Signature
of Applicant/Operator
____________________________________
__________________________________
Type: Position Date
____________________________________
__________________________________
Type: Name and Date
Signature
of Co-permittee*
_____________________________________
__________________________________
Type: Position Date
A. PROPERTY OWNER'S CERTIFICATION
I hereby certify that
____________________________________________________________
Property Owner's Name
is the owner of the property upon which the proposed work is to be done.
This endorsement is certification that the owner grants permission for the
conduct of the proposed activity and authorizes that staff of DEP may conduct
on-site inspections as necessary for the review of this application.
In addition, the aforementioned property owner shall certify:
1. Whether any work is to be done within an easement -
Yes __________ No __________
(Initial)
(Initial)
2. Whether any part of the entire project will be located within property
belonging to the State of New Jersey
Yes _________ No __________
(Initial)
(Initial)
If "Yes", reviewing agency must notify
the Department of Treasury, Office of Property Management,
CN 226, Trenton, N.J. 08625-0226.
3. Whether any part of the entire project will be located within property
belonging to a municipality or county
Yes ______________ No _____________
______________________________________________
______________________________________________
______________________________________________
Type or Print Name and Address of Owner
if different from Item 1 on Page
1
______________________________
_____________________________________________
Date
Signature of Owner
B. APPLICANT'S AGENT
I, the Applicant/Owner _________________________________________________________or Applicant/Operator when the owner of the facility and the operator of the facility are distinct parties) ______________________or Co-permittee (when the Co-permittee is a local governmental unit) ___________________________________________authorize to act as my agent/representative in all matters pertaining to my application the following person:
Name ___________________________________Phone
______________________________
Address ________________________________County
_______________________________
City or Town ______________________State ___________________Zip
Code ____________
Occupation/Profession
__________________________________________________________
_______________________________________
(Signature
of Applicant/Owner)
_______________________________________
(Signature
of Applicant/Operator)
_______________________________________
(Signature of Co-permittee)*
AGENT'S CERTIFICATION
Sworn before me
this ______day of
_________ 19__
I agree to serve as agent for the
above
-mentioned applicant
______________________________________
_________________________________________
Notary Public
(Signature of Agent)
C. STATEMENT OF PREPARER OF PLANS, SPECIFICATIONS, SURVEYOR'S OR ENGINEER'S
REPORT
I hereby certify that the engineering plans, specifications and engineer's
reports applicable to this project comply with the current rules and regulations
of the State Department of Environmental Protection with the exceptions as
noted.
______________________________________
(Signature of Engineer/Architect)
_______________________________________
Type: Name and Date
______________________________________
Position, Name of
Firm
PROFESSIONAL ENGINEER'S/ARCHITECT'S
EMBOSSED SEAL