Conditionally Exempt Small Quantity Generator (CESQG) Waste Approval Form

This form is to be completed by the Conditionally Exempt Small Quantity Generator (“CESQG”) intending to participate in a one-day collection, in accordance with the requirements of the General Permit to Perform One Day Collections of Certain Wastes and Household Hazardous Waste.. Print or type unless otherwise noted.

Part I: One-Day Collection Information

1. Date of the one-day collection:
2. Location/address of the one-day collection:
3. Organizer of the One-Day Collection or Permit Holder:
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext. Fax:
Contact Person: Title:
Email Address:
4. Current permit or registration number: Date issued:

Part II: Conditionally Exempt Small Quantity Generator Information

1.  CESQG Name:
Facility Address:
City/Town: State: Zip Code:
Business Phone: ext.
2.  Primary Contact Person:
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.
Email address:

DEEP-RCY-APPROVAL-007 1 of 4 Rev. 10/14/14

Part III: Waste Information

List the specific hazardous or universal wastes and the associated quantities proposed to be brought to the one-day collection by the CESQG listed in Part II of this form.

Type of Waste or
DOT Class and Division
/
EPA Waste Code
(e.g. D001 or CR02) / Amount
(Gallons or Pounds/Tons)
Example: Ignitable (solvents, oil based paint) / D001 / 20 gallons


Part IV: Waste Characterization

For each hazardous or universal waste listed in Part III of this form, describe how it was determined that the waste is a hazardous or universal waste. Please check either: Information provided on the container label, Material Safety Data Sheet (“MSDS”), Knowledge of the generating process, Analytical testing or other.

Waste Type or
DOT Class and Division
/ Container
Label / MSDS / Knowledge of Process / Analytical Testing / Other
(Please specify)

DEEP-RCY-APPROVAL-007 1 of 4 Rev. 10/14/14

Part V: Certification

The CESQG must sign this part. The form will be considered incomplete unless the required signature is provided.

“I certify that during any of the previous three (3) months that: I have not generated more than two hundred twenty (220) pounds total of hazardous waste; I am not currently storing more than two thousand two hundred (2,200) pounds of hazardous wastes; and that I meet the definition of a Conditionally Exempt Small Quantity Generator (CESQG) as defined in the General Permit to Perform One Day Collections of Certain Wastes and Household Hazardous Waste.
I also certify that this approval form is on complete and accurate forms as prescribed by the commissioner without alteration of the text.”
Signature of Generator or Transporter / Date
Name of Generator or Transporter (print or type) / Title (if applicable)
Check here if additional signatures are required. If so, please reproduce this sheet and attach signed copies to this sheet.

Note: This form must be submitted to the Permittee/Registrant or the Organizer of the one-day collection no later than five (5) calendar days prior to the collection event in accordance with the requirements of the General Permit to Perform One Day Collections of Certain Wastes and Household Hazardous Waste.

DEEP-RCY-APPROVAL-007 1 of 4 Rev. 10/14/14