Municipal Solid Waste (MSW)Licensing Program

Municipal Solid Waste (MSW)Licensing Program

Application Supplement

MC 178, PO Box 13087, Austin, TX 78711-3088

Phone: (512) 239-6133 Fax: (512) 239-6272 Website: www.tceq.texas.gov/licensing

TCEQ-20760 May, 2017 Version 1.1 Page 2 of 2

Name: Date: SSN (Last 4 digits):

Select the type of (MSW) License you are applying for: -- Select one --MSW Class AMSW Class BMSW Class A Provisional (NOT RENEWABLE)MSW Class B Provisional (NOT RENEWABLE)Upgrade from Provisional

Work Experience – List only your work experience and dates experience was obtained in solid waste operations and maintenance. List your most recent employers first

Current Employer:

Facility Name: Job Title:

Your dates of employment (MM/DD/YYYY): From: To:

Facility’s Mailing Address:

City: State: Zip Code:

Supervisor’s Name: Supervisor’s Phone:

Please describe in detail your solid waste operational and maintenance duties:

Previous Employer:

Facility Name: Job Title:

Your dates of employment (MM/DD/YYYY): From: To:

Facility’s Mailing Address:

City: State: Zip Code:

Supervisor’s Name: Supervisor’s Phone:

Please describe in detail your solid waste operational and maintenance duties:

Type of MSW that I will be operating, managing or supervising:

Type I Landfill

Type IAE Landfill

Type IV Landfill

Type IVAE Landfill

Type VI demonstration facility

Type IX landfill mining facility

Type V storage and processing facility not otherwise specified

Type IX energy or material recovery facility (other)

Permitted compost facility

Registered compost facility

The MSW facility that I will be operating, managing, or supervising processes:

Compost Medical Waste

Please attach additional pages if necessary to accurately reflect your experience.

I affirm that the above information is true and correct. I understand that fraudulent or falsified information could result in denial of this application pursuant to Tex. Admin. Code § 30.33 or revocation of my license pursuant to Tex. Water Code § 7.303.

Entering your name in the Signature box constitutes an electronic signature and is legally equivalent to your written signature.

Signature Date

FOR TCEQ USE ONLY

Type of MSW Facility (circle) / Experience / Course Training / Fees / Education
(circle) /
Type I
Type IAE
Type IV
Type IVAE
Type V
Type VI
Type IX
Compost
Other / Years:
Months:
Manager of Landfill Operators (MOLO) certification: / MSW A:
MSW B:
MSW Specialized Training Course for:
Medical Waste
Compost / Amount Paid:
Date Paid:
Reviewer: / HS/GED
BS
MS
Lic #: / Issue Date: / Reviewed By:

TCEQ-20760 May, 2017 Version 1.1 Page 2 of 2