Title 1 Authorites, Boards and Commissions
500 Delaware Solid Waste Authority
504 DSWA Forms - Attachments A, B and C
Attachment A
TO: DELAWARE SOLID WASTE AUTHORITY
P. O. BOX 455
DOVER, DE 19903-0455
I hereby apply for a Solid Waste Collectors License for the period of July 1, 20 through June 30, 20 , in accordance with the Regulations of the Delaware Solid Waste Authority. Accordingly, the following is submitted:
(Note: This application will not be processed unless all requested information is provided. Each application must be accompanied by:
Proof of insurances as required by Section 3.04;
The minimum Bond or Surety, as required by Section 3.10; and,
The vehicle information as requested in Attachment A of this application.)
A copy of your Delaware Business License.
Name of Applicant (Individual or Firm Name):
Company/Trade Name:
Business Office address/telephone numbers (One number MUST be a Delaware number):
OFFICE |
ADDRESS |
PHONE # |
A. |
( ) | |
Street CityState Zip |
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B. |
( ) | |
Street CityState Zip |
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C. |
( ) | |
Street CityState Zip |
Name, Address & Telephone Number of Answering Aervice if Applicable:
NAME |
ADDRESS |
PHONE # |
( ) | ||
Street CityState Zip |
||
( ) | ||
Street CityState Zip |
||
( ) | ||
Street CityState Zip |
Name of Individuals Having Administrative Responsibility at Each Business Location:
NAME |
ADDRESS |
PHONE # |
( ) | ||
Street City State Zip |
||
( ) | ||
Street City State Zip |
||
( ) | ||
Street City State Zip |
Name, Address, Telephone Number of Registered Agents or Authorized Representatives:
NAME |
ADDRESS |
PHONE # |
( ) | ||
Street City State Zip |
||
( ) | ||
Street City State Zip |
||
( ) | ||
Street City State Zip |
Type of Business:
Sole Proprietorship
Partnership
Municipality
Corporation*
* If Non-Delaware Corporation, provide proof of Delaware Registration
Date Business was Established:
Delaware Business License Number: (contact Division of Revenue)
DNREC Waste Haulers Permit Number:
Delaware Business License Renewal Date:
Federal Taxpayer Identification Number:
Name and Address of Owners or Partners in Unincorporated Business. Indicate Respective Ownership Interest on a Percentage Basis:
NAME |
ADDRESS |
% |
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
Name and address of Officers, Directors, Shareholders holding in excess of 10% of issued Stock in incorporated business:
NAME |
ADDRESS |
% |
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
||
Street City State Zip |
Indicate if any partnership or corporation other than applicant has any interest, direct or indirect, in the license applied for, or in the business conducted under such license. (If so, state names & addresses and interest of the partnerships, corporations and principles involved, indicating the nature and extent of the interest.)
Not applicable
Provide details if applicable:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Indicate if any individual, partnership or corporation other than applicant receives or will receive (by way of rent, salary or otherwise) all or any portion of percentage of the gross or net profits or income derived from business conducted under license applied for:
Not applicable
Provide details if applicable:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Indicate if your company or parent company has ever been convicted of civil or criminal offenses concerning waste transporting, processing, or disposal.
No
Yes (provide details on separate sheet)
Indicate if the applicant, any person mentioned in the application, or any person having a beneficial interest in the application has ever been denied an application to collect solid waste.
Not applicable
Provide details if applicable:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
State general area served by applicant:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Indicate days of the week collections are made:
Mon Tue Wed Thur Fri Sat Sun
Daily average weight of Household solid waste collected:______________Tons
Daily average weight of Municipal solid waste collected: ______________Tons
Daily average weight of Commercial/Industrial solid waste collected:_________________Tons
Indicate location(s) where solid waste is being or will be delivered:___________________Tons
TYPE OF WASTE |
LOCATION DELIVERED |
Statement of experience in solid waste collection, transportation, and/or disposal:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
I HEREBY CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHED HERETO IS TRUE AND CORRECT AND THAT I HAVE READ AND AM FAMILIAR WITH THE REQUIREMENTS OF THE REGULATIONS OF THE DELAWARE SOLID WASTE AUTHORITY.
________________ ______________________________________________
Date Signature of Applicant Title
STATE OF_________________________ COUNTY OF________________________________
Before me appeared_____________________________________ , who under oath certifies that the information provided in this application is true and correct.
_____________ ______________________________
Date Notary Public
Attachment B
TRANSFER STATION MONTHLY SOLID WASTE REPORT
From: Reporting Period:
To: Delaware Solid Waste Authority Date:
TYPE OF WASTE |
TONS RECEIVED |
TONS DISPOSED |
DISPOSAL FACILITY Tons Location | |
SOLID WASTE DSWA REGULATIONS, SECTION 5 | ||||
a. Delaware |
1. |
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2. |
||||
3. |
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4. |
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b. Other |
1. |
|||
2. |
||||
3. |
||||
4. |
||||
TOTAL |
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INDUSTRIAL PROCESS WASTE DSWA REGULATIONS, SECTION 3 | ||||
a. Delaware |
1. |
|||
2. |
||||
3. |
||||
4. |
||||
b. Other |
1. |
|||
2. |
||||
3. |
||||
4. |
||||
TOTAL |
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GRAND TOTAL |
CERTIFICATION I hereby certify that the above information is true and correct, to the best of my knowledge, this day of , A.D. 20 .
__________________ __________________________
Notary Public President
Attachment C
SOLID WASTE HAULER REPORT FOR WASTE GENERATED IN DELAWARE AND DELIVERED AND/OR DISPOSED AT OTHER THAN DSWA FACILITY
From: Reporting Period:
To: Delaware Solid Waste Authority Date:
TYPE OF WASTE |
TONS RECEIVED |
TONS DISPOSED |
DISPOSAL FACILITY Tons Location | |
SOLID WASTE DSWA REGULATIONS, SECTION 5 | ||||
a. Delaware |
1. |
|||
2. |
||||
3. |
||||
4. |
||||
b. Other |
1. |
|||
2. |
||||
3. |
||||
4. |
||||
TOTAL |
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INDUSTRIAL PROCESS WASTE DSWA REGULATIONS, SECTION 3 | ||||
a. Delaware |
1. |
|||
2. |
||||
3. |
||||
4. |
||||
b. Other |
1. |
|||
2. |
||||
3. |
||||
4. |
||||
TOTAL |
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GRAND TOTAL |
CERTIFICATION I hereby certify that the above information is true and correct, to the best of my knowledge, this day of , A.D. 20 .
__________________ __________________________
Notary Public President