WASTE COLLECTION EVENT APPLICATION for Conditionally Exempt Generators (CEGs) of Hazardous Waste and Generators of Waste Pesticides Please mail or fax, e-mail completed application within 1 week of the scheduled event to: Stericycle Environmental Solutions Phone: (360) 772-2838 Attn.: John Pitman Fax: (360) 835-8872 625 S. 32nd Street e-mail: John.Pitman@stericycle.com Washougal, WA 98671 Hazardous waste disposal charges are due prior to collection of the waste and may be in the form of cash, check, money order or credit card. Any billing arrangements must be made in advance with Stericycle. Event Location: Event Date: 1. Generator Information Generator Name Type of Business Mailing Address Site Address (if different) City State Zip Code ( ) ( ) Contact Person Telephone Number Fax Number Email 2. Inventory of wastes you want to dispose of at this collection event Please complete the attached waste inventory sheet to list the wastes you will bring to the collection event. Make additional copies of the inventory sheet if needed. Return the completed inventory sheet(s) with this application. Instructions for completing the waste inventory sheet are on the back side of the form. Only wastes that have been pre-registered and approved by Stericycle will be accepted at the collection event. Remember you are limited to no more than 2,000 pounds of Conditionally Exempt Generator waste at this event. Radioactive materials, explosives, infectious medical wastes, certain poisons, very reactive wastes, and unknown wastes are not accepted at these events. There is no quantity limit for collection of waste pesticides. 3. Estimating your disposal costs 1 6/6/16
Using the price information on the waste inventory sheet, you can calculate your disposal costs for the collection event.. The cost depends on the amount and type of waste you bring to the collection event. If you prefer, Stericycle will complete the cost portion of the inventory sheet. Add the waste costs on the inventory sheet(s), and insert below to calculate your estimated total waste disposal cost: Inventory Sheet(s) Total: $ General Waste Description Disposal Costs Antifreeze/Coolants/Motor Oil $3.75/gallon Paints, Non Chlorinated solvents $8.50/gallon Chlorinated Solvents $9.50/gallon Corrosives, Oxidizers $17.00/gallon Metallic Mercury (thermometers, switches) $87/per gallon $85.00 minimum Poisons $17.00 gallon or $3.00/pound Small Chemical Containers <1pound or <100 ml $11.00 each Fluorescent light $.30 / lineal foot CFL s/hid bulbs $1.00/CFL, $3.00/small HID, $6.00/ large Light ballasts <9lb non leaking $ 6.00 / each Light ballasts >9lb or leaking $ 22.00 / each Other Wastes Call Stericycle at 1-800-547-2436) Need more information on hazardous waste management? DEQ has Technical Assistance staff located throughout the state. They can help you understand the hazardous waste regulations, help you properly identify and manage hazardous waste on-site and identify potential waste reduction and recycling opportunities. Assistance is provided by telephone, on-site visits, presentations and workshops. If you have ever wondered whether you are in compliance with the hazardous waste regulations or have questions about the hazardous waste you generate, the DEQ Technical Assistance program can help. For more information about the DEQ Technical Assistance program or to arrange an on-site visit, please contact the regional office nearest you: Eastern Region 2146 NE 4th, Suite 104 Bend, OR 97701 (541)388-6146 -or- 700 SE Emigrant, Suite 330 Pendleton, OR 97801 (541) 276-4613 Western Region 750 Front St. NE, Suite 120 Salem, OR 97310 378-8240, ext. 253 or 258 -or- 725 SE Main St. Roseburg, OR 97470 (541) 440-3338, ext. 230 Northwest Region 2020 SW 4th, Suite 400 Portland, OR 97201 (503) 229-5263 2 6/6/16
4. Certification for Conditionally Exempt Generators Note: This page must be completed and submitted with the application if you are disposing of CEG waste at this event. If you are only disposing of waste pesticides at this event, you do not need to sign and submit this page with your application. State and federal hazardous waste regulations limit the use of CEG hazardous waste collection programs to those businesses that generate 100 kilograms (approximately 220 pounds or 25 gallons) of hazardous waste per month. Businesses that generate more than this amount must use a licensed hazardous waste hauler to manifest and transport their waste. Therefore, we are requesting that you sign the following certification before disposing of your waste at the collection event: I certify that my business generates less than 220 pounds of hazardous waste and 2.2 pounds of acutely hazardous waste per month. I also certify that I have not accumulated more than 2,200 pounds of hazardous waste (2.2 pounds of acutely hazardous waste) at this time. I understand that I must pre-register and pay the disposal cost before I can drop off my wastes at the collection event. I also understand that only the types and quantities of wastes listed on the Inventory Sheet(s) in Section 2 have been approved by Stericycle for disposal at the collection event. Finally, I understand that the state, local government or Stericycle does not assume liability for my wastes, and that future liability remains with my business. Company Representative (print or type) Generator (Company) Name Generator (Company) Address EPA/DEQ I.D. # (if company has one) Signature of Company Representative 3 6/6/16
Instructions For Completing Waste Inventory Sheet 1. Item Number: Number each item (or category group of items) you want to dispose of at the collection event. Each item should have an individual number on its container as reference. The container number should correspond to the completed inventory sheet(s) submitted to Stericycle. 2. Waste Description: Describe, in as much detail as possible, wastes that you want to dispose of at the collection event. The description should include the chemical and trade name, how you use the material, physical state (i.e., liquid, solid, sludge, gas), chemical characteristics (e.g., flammable/ignitable), and chemical constituents and percentages from the label or material safety data sheet (MSDS). For pesticides (e.g., herbicides, fungicides, rodenticides, etc.), please include the EPA registration number if available, trade name and percent concentration. When listing waste quantities, be accurate as possible. DO NOT include wastes you do not want to dispose of at the collection event, nor containers of unknown waste substances. Please avoid mixing your wastes together. 3. Quantity: List the quantity of waste you want to dispose of at the collection event. As a rule, list liquids in gallons and solids and sludge in pounds. 4. Cost per Pound or Gallon of Waste Disposed: Refer to waste disposal costs at the bottom of the Inventory Sheet. For wastes not listed on the Inventory Sheet, please call Stericycle at 1-800-547-2436 for a cost estimate. 5. Disposal Charge: Quantity of waste multiplied by the cost per pound or gallon will determine the disposal charge for each waste. Regardless of quantity, each item on the Inventory Sheet will receive a minimum charge of one pound or one gallon. For example, a quarter gallon of latex paint will have a minimum disposal cost for one gallon of latex paint. 6. Total Charge this Sheet: This box is the Disposal Charges column added together for each Inventory Sheet. For a business with multiple Inventory Sheets, the last Inventory Sheet should also list the sum of all the Total Charge This Sheet box from each Inventory Sheet. The sum of the Total Charge This Sheet box is the dollar figure you enter in Section 3 of the Application form. For questions, please contact Stericycle. Once Stericycle has received and reviewed your application, you will receive a letter and/or telephone call acknowledging acceptance of your application. The acknowledgment letter and/or call will provide you with the total estimated cost for disposal of your waste, an appointment time for bringing in your waste, and any changes to the collection event site. 4 6/6/16
Waste Inventory Sheet for Collection Event (Copy and use additional sheets if needed) Item Number Waste Description Quantity (lbs. or gals.) Cost (per lb. or gal.) Disposal Charge Total Charge This Sheet Waste Description Cost Waste Description Cost Antifreeze/Coolants/Oil $3.75/gallon Poisons/ Pesticides $17.00/gal.or $3.00/lb Non Chlorinated Solvents Including paints $8.50/gallon Small Chemical Containers (<1pound) $11.00 each Chlorinated Solvents $9.50/gallon Fluorescent tubes.30/lineal foot Corrosives, Oxidizers $17.00/gallon Other Wastes Call Stericycle (1-800-547-2436) Metallic Mercury (thermometers, switches) $87/gal. minimum $85 Waste Inventory Sheet -- Page of Light ballasts <9lb non leaking $6.00/each 5 6/6/16