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Santa Clara County Hazardous Waste Material Generator Permit

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Santa Clara County Hazardous Waste Material Generator Permit Powered By Docstoc
					County of Santa Clara
Department of Environmental Health
Hazardous Materials Compliance Division
1555 Berger Drive, Suite 300
San Jose, CA 95112-2716
(408) 918-3400; Fax (408) 280-6479
www.EHinfo.org/hazmat


            HAZARDOUS WASTE GENERATOR PERMIT APPLICATION
    First-Time Application
    New Owner
    Business Moved
    Change of Information         Business Name (DBA):

Site Address:                                                                                                                              City:                                           Zip:

Mailing Address:                                                                                                               City:                                           State:           Zip:
                        If different from site address.


Business Owner Name(s):
                                            If owner is a corporation, LP, or LLC, note the name exactly as it is registered with the California Secretary of State.


Proprietor/Billing Contact Name:                                                                                                                      eMail Address:
                                                          If different from owner.


Billing Address:                                                                                                               City:                                           State:           Zip:
                     If different from mailing address.



Facility Phone No.: (                     )                                          Fax No.: (                         )                                       Days/Hours of Operation:

Contact Person:                                                                                                                              Contact Phone No.: (                 )                     ext.

Principal Type of Business (e.g., auto repair, photoprocessing):                                                                                                                                 Owned by Individual
                                                                                                                                                                                                 Partnership
                                                                                                                                                                                                 Corporation or LLC
                                                                                                                                                                                                 Other
EPA ID Number:
Hazardous Waste Inventory Information:
The annual permit fee is determined by the total quantity of hazardous waste generated per year. Complete the table below for all
hazardous waste inventory (e.g., used oil, used parts cleaning solvent, waste paint, spent fixer, etc.).
                     Name of                                   Treatment/Disposal Method(s)              Annual Quantity
                 Hazardous Waste                              (Definitions provided on back of form.)      Generated*
                                                               Recycled on-site.                                                                                                                               gal.
                                                               Treated on-site.                                                                                                                                lbs.
                                                               Shipped off-site for recycling/treatment/disposal.
                                                               Recycled on-site.                                                                                                                               gal.
                                                               Treated on-site.                                                                                                                                lbs.
                                                               Shipped off-site for recycling/treatment/disposal.
                                                               Recycled on-site.                                                                                                                               gal.
                                                               Treated on-site.                                                                                                                                lbs.
                                                               Shipped off-site for recycling/treatment/disposal.
                                                               Recycled on-site.                                                                                                                               gal.
                                                               Treated on-site.                                                                                                                                lbs.
                                                               Shipped off-site for recycling/treatment/disposal.
                                                               Recycled on-site.                                                                                                                               gal.
                                                               Treated on-site.                                                                                                                                lbs.
                                                               Shipped off-site for recycling/treatment/disposal.
                                                               Recycled on-site.                                                                                                                               gal.
                                                               Treated on-site.                                                                                                                                lbs.
                                                               Shipped off-site for recycling/treatment/disposal.
                                                               Recycled on-site.                                                                                                                               gal.
                                                               Treated on-site.                                                                                                                                lbs.
                                                               Shipped off-site for recycling/treatment/disposal.
*   Solids must be reported in pounds. Liquids may be reported in either pounds or gallons.
The undersigned hereby applies for a Hazardous Waste Generator Permit from the County of Santa Clara. I hereby certify
that the submitted information is true, accurate, and complete. I understand that a new application will be required if this
facility changes ownership, moves, or begins generating hazardous wastes which are not listed on this application.

Signature of Owner/Operator:                                                                                                          Title:                                            Date:

HMCD-005                                                                                            www.EHinfo.org/hazmat                                                                               Rev. 08/30/10
Hazardous Waste Generator Permit Application - Page 2 of 2


                                                   Definitions of Treatment/Disposal Methods

Recycled on-site: The facility takes the waste or any constituent of the waste, treated or not, and reuses it on-site or ships it off-site
as an Excluded Recyclable Material.
Treated on-site: The facility employs any method, technique, or process which changes or is designed to change the physical,
chemical, or biological character or composition of the hazardous waste or any material contained therein, or removes or reduces its
harmful properties or characteristics for any purpose including, but not limited to, energy recovery, material recovery, or reduction in
volume (e.g., pH adjustment, evaporation, precipitation, filtration, distillation, compacting, etc.). If, after treatment, the material is
reused at the facility, the “Recycled on-site” box in the waste inventory table should be checked.
Shipped off-site for recycling/treatment/disposal: The facility sends the waste, or any hazardous treatment residual, to an off-site
permitted treatment, storage, or disposal facility (TSDF).
Note: Depending on how a waste or its constituents are recycled and/or treated, more than one treatment/disposal category may
apply. All applicable boxes in column 2 of the waste inventory table should be checked.
Note to medical facilities: Do not list medical (i.e., red bag) wastes on this form.

Agency Use Only
                                                                     HMS STAFF
Location:                                                                                    Create Special Program Record(s):
   MJ–Multi-Jurisdiction                                                                        5001-State Hazardous Materials Service Fee
                                                                                                2224-Onsite HazWaste Recycler ≤100 Kg/Mo
City Code:
                                                                                                2225-Onsite HazWaste Recycler >100 Kg/Mo
   01–Palo Alto                  02–Los Altos                   03–Los Altos Hills
                                                                                                2241-Universal Waste Generator Only
   04–Mountain View              05–Cupertino                   08–Milpitas
                                                                                                2242-Universal Waste Consolidation Site
   09–Campbell;                  10–Saratoga                    11–Los Gatos
                                                                                                2243-Universal Waste Dismantler
   12–Monte Sereno               13–San Jose                    14–Morgan Hill
                                                                                                2261-Permit by Rule (PBR) x ______ units*
   16–County Area;               19–Stanford                    20–San Martin
                                                                                                2262-Conditionally Authorized (CA) x ______ units*
   21–Moffett Field
                                                                                                2263-Conditionally Exempt (CE) x ______ units*
Business Code:                                                                                  2299-HazWaste Generator Program Record
   01–Corporation/LLC            02–Individual                  03–Partnership                  Other (specify): __________________________
   04–Local Agency               05–County Agency               06–State Agency
                                                                                             Special Handling:
   07–Federal Agency             99–Unknown
                                                                                             Set Date of Last Billing as: ____________________
Business Type:                                                                               Permit is Valid from: _________________________
   04-HazWaste Only;             08-Multi-HazMat;               10-Multi-Program             Permit is Valid to: ___________________________
Designated Employee (inspector): __________________                                              Do not bill now
Mail To:
  01-Owner Mailing Address;                  02-Facility Mailing Address                                         SUPPORT STAFF
Program Element (PE): __________________
                                                                                             Owner ID: _________________________________
Current Status:
  01-Active;                     04-Active, exempt from billing                              Multiple Owner ID: _________________________
Discount Code:                                                                               Multiple Owner ID: _________________________
   No Discount;                  ______ Month Discount
                                                                                             Facility ID: ________________________________
Permit Status:
   21-Full, Ongoing Permit;                  15-Billed by Mountain View                      Program Record ID: ________________________
   18-Billed by San Jose
                                                                                             Program Record ID: ________________________
Permit Type:
   P-Permanent;                              PE-Permanent Exempt                             Permit Record ID: _________________________
                                                                                             Account Record ID: _________________________
Comments:         * For Tiered Permit Program Records, a fee is charged only for the first unit in the highest permitted tier (PBR > CA > CE).




Prepared by: _______________________________________________                                  Date: __________________________________
Senior/Manager Initials: __________ Date: _________________                                   Input by: ________ Date: ____________
HMCD-005 - 2/2                                                    www.EHinfo.org/hazmat                                                          Rev. 08/30/10

				
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