HomeMy WebLinkAboutTransfer Station Forms
(DEPT. USE ONLY)
OEe APPLICATION #
DEPARTMENT OF ENVIRONMENTAL CONTROL
TRANSFER STATION I RECYCLING CENTER PERMIT APPLICATION
TYPE OF PERMIT (Check all applicabla boxes)
Or-eN
o RENEWAL
o MOOIFlCAllON
OWNERSHIP:
LOCA llON:
FACILITY OWNER NAME
FACILITY OWNER NAME
ADDRESS
ADDRESS
TOWN I STATE I ZIP
TOWN I STATE I ZIP
TELEPHONE
TELEPHONE
NEW YORK STATE DEC TRANSFER STATION PERMIT NUMBER
EXPIRATION DATE
EFFECTIVE DATE
List all officers by name and title, and all persons wRh financial Interest In this application as follows: the application shall contain the na"'e
of the applicant or, If a partnership or corporation, the names of all partners, officers, directors and all persons holding 5% or more of the
outstanding shares of said corporation. If the applicant Is a corporation which Is wholly or partially owned by another corporation, the
parent corporation shall be Identified together wRh the name of the officers and director of the parent corporation.
Type of Ownership: 0 Sole Proprietorship 0 Par1nership 0 Corporation
(If owned by parent corporation, provide information on additional sheet.)
A. OFFICER I PARTNER B. OFFICER I PARTNER
NAME NAME
ADDRESS ADDRESS
TOWN I STATE I ZIP TOWN I STATE I ZIP
C. OFFICER I PARTNER D. OFFICER I PARTNER
NAME NAME
ADDRESS AODRESS
TOWN I STATE I ZIP TOWN I STATE I ZIP
Have you or any parson listed above been convicted of a violation of the law, other than a traffic violation?
DYes
o No
If yes, explain:
Pao81
CAPACITY REQUEST I PRELIMINARY RECOVERY ESTIMATE
Types of Waste to be Accepted:
o Commercial Solid Waste
o Construction and Demolition Debris
o Other (please specifiy)
QUANTITIES TO BE ACCEPTED: MATERIALS TO BE RECOVERED:
Commercial Solid Waste: tons/day vdsJday o Newspapers o Corrugated Cardboard
Construction and Demolition: tons/day yds'day o Glass o Ferrous
Other: tons/day vds'day o Plastic o Mixed Paper
o Aluminum
Other: tons/day vdsJday o Other (please specify)
PLEASE DESCRIBE SEPARATION SYSTEM TO BE EMPLOYED (i.e. hand sorted or automated):
LIST CARTING FIRMS FROM WHOM WASTE WILL BE ACCEPTED: (attach add/tional sheets if needed)
A. FIRM 1:
B. FIRM 2:
NAME
NAME
ADDRESS
ADDRESS
TOWN/STATE/ZIP
TOWN/STATE/ZIP
TELEPHONE
TELEPHONE
C. FIRM 3:
D. ARM 4:
NAME
NAME
ADDRESS
ADDRESS
TOWN / STATE / ZIP
TOWN/STATE/ZIP
TELEPHONE
TelEPHONE
Page 2
WilL MATERIAL BE ACCEPTED FROM OUTSIDE THE TOWN 0 YES 0 NO
IF YES, LIST THE CARTING FIRM AND THE JURISDICTION FROM WHERE MATERIAL WILL BE COLLECTED:
(attach additional sheets il needed)
FIRM I JURISDICTION
FIRM I JURISDICTION
FIRM I JURISDICTION
FIRM I JURISDICTION
FIRM I JURISDICTION
FIRM I JURISDICTION
PLEASE LIST MARKETS I OUTLETS FOR RECOVERED MATERIALS (NAME & LOCATION ):
NEWSPAPER
GLASS
PLASTIC (identify types)
ALUMINUM
CORRUGATEDCARD80ARD
FERROUS METAL
MAGAZINES
MIXEO PAPER
PLEASE IDENTIFY DISPOSAL FACILITIES FOR RESIDUAL WASTES:
NAME I LOCATION:
NAME I LOCATION:
NAME I LOCATION:
NAME I LOCATION:
Page 3
8TATE OF NEW YORK)
: 8.S.
COUNTY OF )
, being duly sworn,
deposes and says that he/she is the of
. the applicant
herein; that all the information submitted with this application is true; that the applicant
agrees to comply with all provisions of Chapter 21 of the Code of the Town of Islip which
regulates the collection and disposal of solid waste and the operation of Transfer
Stations/Recycling Centers; that the applicant understands that failure to comply with the
rules and regulations of the Town of Islip or any false statements made on any part of this
application shall be grounds for denial and/or revocation of this permit.
SIGNATURE
ACTION BY TOWN CLERK:
(A) Approved:
Permit No.
. expires:
(B) Disapproved:
EFFECTIVE DATE
PERMIT *
PERMIT TO OPERATE
TRANSFER STATION I RECYCLING CENTER
EXPIRATION DATE
TYPE OF PERMIT (Check an applicable boxe.):
o NEW
o RENEWAL
o MODIFICATION
PERMIT ISSUED TO: I TELEPHONE NUMBER:
( )
ADDRESS OF PERt,lITTEE:
CONTACT PERSON FOR PERMITTED WORK: I TELEPHONE NUMBER:
( )
NAME AND ADDRESS OF FACILITY I COMPANY:
!
DESCRIPTION OF AUTHORIZEO ACTIVITY:
.
.
By acceptance of this permit. the permittee agrees that the permit is contingent upon strict compliance with Chapter 21 of the Town Code.
all applicable regulations, the General Conditions spec.ified (see reverse side) and any special conditions included as parl of this permit.
Dept. of Environmental Control Town of Islip Dept. of Environmental Control
. - 401 Main Street, Isllp, NY 11151
AuthoriZed Signature Data
Page 1 of
GENERAL CONDITIONS
Transfer Station I Recycling Center
INSPECTIONS:
1. The permitted site or facility. including relevant records. is subjeClto inspection at reasonable hours
and intervals by an authorized representative 01 the Department 01 Environmental Control to determine
whether the permittee is complying wkh this permk and Chapter 21 01 the ToNn oIlsllp Code. A copy
01 this permit, including all referenced maps. drawings and special conditions. must be available lor
inspection by the Department at all times at the project site. Failure to produce a copy 01 the permit
upon request by a Department representative. Is a violation 01 this permit.
PERMIT CHANGES AND RENEWALS:
2. The Department reserves Ihe righlto modify. suspend or revoke this permit when:
a) the scope d the permitted activity is exceeded or a violation d any condition d the permit or provisions
01 the Chapter 21 and pertinent regulations is Iound;
b) the permit was obtained by misrepresentation or failure to disclose relevant facts;
c) new material informallon is discovered; or
d} environmerCal conditions. reIevanI technology, or appIlcab1e law or regulationS have materially changed
since the permit was issued.
3. The permittee must submit a separate written application to the Department lor renewal. modification
or transfer 01 this permit. Such application must include any Iorms. lees or supplementallnlormation
the Department requinls. Any renewal, modification or transfer granted by the Department must be
in writing. "......,...".
4. The permittee must submit a -' appIicalionat least.30 days b8f0re.expinIlion~uf .8llJSling ~"; .~... -.'
S. Unless expressly provided for the Department. issuance 01 this permit does nOt modify, supercede or
rescind any order 01 determination previously issued by the Department or any ollhe terms, conditions
or requirements contained in such order or determination.
OTHER OBUGATIONS OF PERMITTEE:
6. The permittee has accepled expressly. by the execution 01 the application. the full legal responsibility
lor all damages. direct or indirect. 01 whatever nature and by whomever suffered, arising out 01 the
project described in lhis permit and has agreed to indemnify and save harmless the lOwn oIlslip from
suits. actions. damages and COS1 01 every name and description resulting lrom Ihis project.
7. This permit does nol convey to the permittee any rights to trespass upon the lands or interfere with
the riparian rights 01 others in order to perform the permitted WOfk nor does it authorize the Impairment
01 any rightS. tkle or interest in real or personal property held or vested in a person nO! a perty 10 the permit.
8, The permittee is responsible lor obtaining any other permits, apprlMlls, land. easements and rights-OI-way
that may be required lor this project.
TOWN of ISLlP
DEPARTMENT OF ENVIRONMENTAL CONTROL
PERMIT TO OPERATE
TRANSFER STATION I RECYCUNG CENTER
(Pursuant to Chapter 21 - Code of the Town of Isllp)
Appendix A
SPECIAL CONDITIONS
1. All applicable special conditions contained in the attached Part 360 Permit issued by New
Yo!1< State Department of Environmental Conservation shall be made a part and special condi-
tions of this Town of (slip Permit to Operate. This shall include a requirement that all quarterty
and annual reports filed by the permittee with New Yo!1< State Department of Environmental
Conservation shall be filed with the Town of Islip Office of Recycling.
2. The permittee shall maintain a record of materials separated at the facility for reuse/recycling
for use by the Town in projecting the amount of commercial wastes recycled in the Town.
3. Applicant to submit a renewal application by December 1.
.
.. ' . ..
GENERAL CONDITIONS
Transfer Station I Recycling Center
INSPECTIONS:
1. The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and
intervals by an authorized representative of the Department of Environmental Control to determine whether
the permittee is complying with this permit and Chapter 21 of the Town of Islip Code. A copy of this
permit, including all referenced maps, drawings and special conditions, must be available for inspection
by the Department at all times at the project site. Failure to produce a copy of the permit upon request by
a Department representative, is a violation of this permit.
PERMIT CHANGES AND RENEWALS:
2. The Department reserves the right to modify, suspend or revoke this permit when:
a) the scope of the permitted activity is exceeded or a violation of any condition of the permit or
provisions of the Chapter 21 and pertinent regulations is found;
b) the permit was obtained by misrepresentation or failure to disclose relevant facts:
c) new material information is discovered; or
d) environmental conditions, relevant technology, or applicable law or regulations have materially
changed since the permit was issued.
3. The permittee must submit a separate written applications to the Department for renewal, modificallOl.
or transfer of this permit. Such application must include any forms, fees or supplemental information the
Department requires. Any renewal, modification or transfer granted by the Department must be in writing.
4. The permittee must submit a renewal application at least 30 days before expiration date of existing
permit.
5. Unless expressly provided for the Department, issuance of this permit does not modify, supercede or
rescind any order of determination previously issued by the Department or any of the terms, conditions,
or requirements contained in such order or determination.
OTHER OBLIGATIONS OF PERMITTEE:
6. The permittee has accepted expressly, by the execution of the application, the full legal responsibility for
all damages, direct or indirect, of whatever nature and by whomever suffered, arising out of the project
described In this permit and has agreed to indemnify and save harmless the Town of Islip from suits,
actions, damages and cost of every name and description resulting from this project.
7. This permit does not convey to the permittee any rights to trespass upon the lands or interfere with the
riparian rights of others In order to perform the permitted work nor does it authorize the impairment of any
rights, title or interest in real or personal property held or vested in a person not a party to the permit.
8. The permittee is responsible for obtaining any other permits, approvals, land, easements and rights-of-
way that may be required for this project.
TOWN OF ISLlP
~
~
DEPARTMENT OF ENVIRONMENTAL CONTROL
Christopher A. Andrade, Commissioner
TRANSFER STATION/RECYCLING CENTER
FACILITY INSPECTION REPORT
FACILITY NAME LOCATION FACILITY NO. DATE
INSPECTOR'S NAME PERSONS INTERVIEWED AND TffiES WEATHER CONDITIONS
DEC PERMIT NUMBER SHEET CONTINUATION SHEET ATTACHED
of DYES DNo
C NIV
ODD
ODD
ODD
ODD
ODD
ODD
ODD
ODD
ODD
ODD
ODD
ODD
o 0 0
ODD
ODD
ODD
ODD
ODD
Violations of Town ofIslip Solid Waste Code are subject to applicable civil, administrative and criminal sanctions.
Additional and/or multiple violations may be described on the attached continuation sheet.
This form is a record of conditions which are observed in the field at the time ofinspection.
Items marked C are in compliance, NI are inspected, and V is in violation.
Permit Pending D Permit Renewed D Complaint D
FACILITY MANAGEMENT
I. Solid waste management facility is authorized and management occurs within approved area.
2. A sign is posted with the hours of operation and the types of solid waste accepted and not accepted.
3. Storage space is adequate for incoming solid waste.
4. Adequate fire equipment is available.
5. Operator maintains and operates facility components and equipment in accordance with the permit and their intent
6. Operational records are available where required.
a. Unauthorized Solid Waste Records.
b. Permit Application records.
c. Monitoring Records.
d. Facility Operator Records.
OPERATION CONTROL
7. Solid waste, including blowing litter, is sufficiently confined or controlled.
8. Dust and dirt is effectively controlled, and does not constitute an off-site nuisance.
9. On-site vector populations are prevented or controlled, and vector breeding areas are prevented.
10. Odors are effectively controlled so that they do not constitute a nuisance.
WATER
II. Solid waste is prevented from entering surface waters and/or groundwaters.
12. All floors are free from standing water.
ACCESS
13. Access to the facility is strictly and continuously controlled by fencing, gates, signs, natural barriers or other suitable.
14. On-site roads are passable.
COMMENTS:
:
TOWN OF IS LIP
DEPARTMENT OF ENVIRONMENTAL CONTROL
401 Main Street
Islip, NY 11751
Eric M. Hofmeister, Commissioner
TRANSFER STATIONIRECYCLING CENTER
QUARTERLY REPORT
Submit the Quarterly Report no later than 14 calendar davs after each quarter ends.
Quarter I is from January 151 to March 31", Quarter 2 is from April I st to June 30th, Quarter 3 is from
July I st to September 30th and Quarter 4 is from October 1st to December 31 st.
Reporting of the information indicated on this Transfer StationIRecycling Center Quarterly Report
form is required pursuant to Chapter 21 of the Town ofIslip Solid Waste Code.
Failure to provide the required information requested is a violation of said Code. Forms should be
filled out completely and returned to:
Town ofIslip
Department of Environmental Control
40 I Main Street
Third Floor Room 302
Islip, NY 11751
Atten: Chris Andrade
Entries on the report forms should be typewritten. Attach additional sheets if space on the pages
is insufficient or supplementary information is required or appropriate.
v
,
QUARTERL Y REPORT
This Transfer Station/Recycling Center Quarterly Report is for the year
1st Quarter 0 2"d Quarter 0 3rd Quarter 0 4th Quarter 0
SECTION 1
Owner/Facility Information
Facility Name
Facility Location
State
Zip
Facility Contact
Phone No. (
)
Fax No. ( )
Town
County
NYSDEC Facility Code or Registration No.
Registered Facility YES NO
360 Permit No._-
/
Issued -----.1-----.1_ Expires -----.1-----.1_
Owner Name
Phone No. L-->
Mailing Address
State
Zip
SECTION 2
Ouantity of SoUd Waste Received
Report the tonnages/cubic yards of solid waste received on Table A.
A. Values were obtained by: (check one)
Scale Weight
Cubic Yards
Initial
Page I of6
TABLE A
r
Type of Solid Waste Quarter Quarter Quarter Quarter Total
1 2 3 4
Gross tons/cubic yards of mixed Solid Waste
and Recyclables
(Residential, Institutional & Commercial)
Gross tons/cubic yards of Construction &
Demolition (C&D) Debris
Gross tons/cubic yards of Asbestos Waste
Gross tons/cubic yards ofIndustrial Waste
(Including Industrial Process Sludges)
Other (Specify:
\
Total Tons Received
Total container's Capacity of all
non-residential stops, and multiple
residence stops serviced by
collection vehicles.
Facilitv's Service Area
IdentifY the location and container capacity of all nonresidential and multiple residences stops
located within the Town ofIslip. (Use separate sheet if needed)
Address of Stop
Container CaDacitv
Initial
Page 2 of6
This information will be treated by the Town as trade secrets, which if disclosed could cause substantial
injury to the competitive position of the person submitting the information.
SECTION 3
Material Recovered
For each type of solid waste recovered, provide the weight in tons or cubic yards.
Values were obtained by: (check one)
Scale Weight
Cubic Yards
Type of Solid Waste Quarter Quarter Quarter Quarter Total
Recovered 1 2 3 4
Aggregate & Concrete
Wood & Wood Chips
Glass
Plastic
Paper
Cardboard
Metals
Other (Specify:
)
Total Tons Recovered
lnitial
SECTION 4
Page 3 of6
Unauthorized Solid Waste
Has this facility received any violations or summonses from any governmental, municipal, or other
agency Yes No. If Yes, give information below.
Date Issuing Agency Contact Person Type of Violation
Received
Has unauthorized solid waste been received at the transfer station during the reporting period?
YES
NO
If Yes, give information below for each incident:
Date Type Received Date Disposal Method & Location
Received Disposed
Transfer\Disposal Destination
Identify the transfer or disposal destination of waste removed by indicating the name of the
transfer/disposal facility, the County, State and the amount transferred.
Transfer Disposal Facility
County
State
Tons
Initial
Page 4 of6
"
SECTION 5
Problems
IdentifY any problems encountered during the reporting period (e.g. specific occurrences which have led
to changes in facility procedures) and methods for resolution of the problems. List submissions
(required by this section) that have been attached to this form or the reasons for not attaching a required
piece of information:
SECTION 6
Chane:es
IdentifY any changes in the operation that have occurred during the reporting period (e.g. equipment,
service area, and operational procedure changes). List submissions (required by this section) that have
been attached to this form or the reasons for not attaching a required piece of information:
SECTION 7
Permit/Consent OrderlRetdstration ReDOmnl! Reauirements
Are there any additional permit/consent order/registration reporting requirements not covered by the
previous sections of this form? Yes No
If Yes, identifY the reporting requirements with their respective responses below, attaching additional
sheets as necessary. List submissions (required by this section) that have been attached to this form or
the reasons for not attaching a required piece of information:
Initial
Page 5 of6
.
SECTION 8
Sipature and Date bv Owner or Operator
NOTE: Owner or Operator must initial each page, sign, date and submit one completed form, with an
original signature to:
Town ofIslip
Department of Environmental Control
40 I Main Street
Third Floor Room 302
Islip, NY 11751
Atten: Chris Andrade
I hereby swear or affirm that information provided on this form and attached statements and exhibits is
true to the best of my knowledge and belief.
Signature
Date
Name (Print or Type)
Title (Print or Type)
!
Address
City
( )
Phone Number
State and Zip
Initial
Page 6 of6
Town of Islip
Transfer Station Documentation
Transfer Station:
Address:
(Coot)
Contact:
Tel#__
Fax#__-
NYSDEC Permit Expiration Date:
Town ofIsIip Permit Expiration Date: Annual
Town ofIsIip Renewal Package
Mailed on:
Received on:
Complete: YES / NO
( If No )
Quarterly Reports
Annual Report
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Year
Year
Year
Year
Year
Comments: