ࡱ> #` fbjbjmm 4vhhhhn :1:1:1:11rKn2p4p4p4p4578KKKKKKK$LhPO)KD<5"5D<D<)Khhp4p4+K===D<hlp4p4K=D<K==rGT,Hp4b2 ڦ:1`<dHIDK0K-HP<PHPHK99r=]:\:K9K9K9)K)K=K9K9K9KD<D<D<D<rrr!Drrr!4H"jhhhhhh  STATE OF MAINE APPLICATION/LICENSE FOR TRANSPORTATION OF NONHAZARDOUS WASTE 1. STATE2. YEAR  MAKE3. VEHICLE I.D. NO FORMTEXT       FORMTEXT       FORMTEXT      FOR TWO OR MORE VEHICLES ATTACH THE FLEET APPLICATION FORM 4.  FORMCHECKBOX  NEW APPLICATION  FORMCHECKBOX  RENEWAL  FORMCHECKBOX  TRANSFER  FORMCHECKBOX  ADDITION 5. APPLICANT NAME FORMTEXT       6. COMPANY NAME FORMTEXT      7. PHYSICAL & MAILING ADDRESS (if different) FORMTEXT      8. CITY / TOWN FORMTEXT       9. STATE FORMTEXT      10. ZIP CODE FORMTEXT      11. TELEPHONE NUMBER FORMTEXT      12. FEDERAL I.D. NUMBER FORMTEXT       13. (CHECK ONE)  FORMCHECKBOX  SOLE PROPRIETOR  FORMCHECKBOX  PARTNERSHIP  FORMCHECKBOX  CORPORATION  FORMCHECKBOX  MUNICIPALITY  FORMCHECKBOX  COUNTY  FORMCHECKBOX  STATE GOVERNMENT  FORMCHECKBOX FEDERAL GOVERNMENT  FORMCHECKBOX  OTHER  FORMTEXT       CATEGORY OF WASTE TO BE TRANSPORTED IN THE ABOVE VEHICLE(S):  FORMCHECKBOX  CATEGORY A SPECIAL WASTE, TIRES, CONSTRUCTION & DEMOLITION DEBRIS  FORMCHECKBOX  CATEGORY B MUNICIPAL SOLID WASTE (trash, garbage, rubbish)  FORMCHECKBOX  CATEGORY C SEPTAGE FEES SUBMITTED: $ FORMTEXT       FEES MUST BE SUBMITTED BY CHECK OR MONEY ORDER PAYABLE TO  TREASURER, STATE OF MAINE  SEE FEE SCHEDULE REQUIRED ATTACHMENTS: (PLEASE CHECK OFF) A.  FORMCHECKBOX  Certificate of Vehicle Insurance with DEP as certificate holder B.  FORMCHECKBOX  Disclosure Statement listing all civil or criminal violations, court proceedings or consent agreements concerning handling of waste. IF NONE, CHECK HERE  FORMCHECKBOX  C.  FORMCHECKBOX  Photocopy of vehicle registration (if applicable) D.  FORMCHECKBOX  Letter of authorization from the Company listed in Section 6 authorizing the applicant to apply for a license on behalf of the Company. By signing this application, I certify that the information contained in and attached to this form is true, correct and complete to the best of my knowledge. (printed or typed):  FORMTEXT       Title:  FORMTEXT       Signature:______________________________________ Date Signed: ______________________ NONHAZARDOUS WASTE TRANSPORTER LICENSE DEPARTMENT OF ENVIRONMENTAL PROTECTION 17 STATE HOUSE STATION AUGUSTA, ME 04333 (207) 287-2651 THIS LICENSE IS NOT VALID UNLESS STAMPED WITH DEPARTMENT SEAL AND DATE Authority for issuing: 38 M.R.S.A. Sections 1304(1) and 1304(1-A) INSTRUCTIONS FOR COMPLETING NON-HAZARDOUS WASTE TRANSPORTER LICENSE APPLICATION Pursuant to 38 M.R.S.A., Sections 1304(1) and 1304(1-A) every owner or operator of a conveyance who transports, transfers, or disposes any solid waste, special waste, or septage within Maine shall license their conveyance with the Department of Environmental Protection. When you have completed filling in the application, please PRINT TWO COPIES and mail both copies to the Maine Department of Environmental Protection. After being stamped with the Department seal, one copy will be returned to you as your license. Mail Completed applications, with fees and attachments, to: Non-Hazardous Waste Transporter License Department of Environmental Protection 17 State House Station Augusta, ME 04333 INSTRUCTIONS: 1. State Enter the state of registration of the conveyance. 2. Year - Make Enter the model year and the manufacturer of the conveyance being licensed. 3. Vehicle I.D. No. In most cases, this will be the VIN shown on the vehicle registration. Conveyances which do not require registration must enter a serial number or other unique identifying number in this space. 4. Please mark all appropriate boxes. New application means the conveyance has not been licensed to transport non hazardous waste in Maine. Renewal means re-licensing, prior to license expiration, of a conveyances non hazardous waste transport license. Transfer means transfer of one or more conveyance licenses to another owner or leasee after sale or lease of the conveyance(s). Addition means the adding additional conveyances to an existing license. 5. Applicant Name This is the name of the person applying for a license on behalf of the entity listed in Section 13. 6. 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Physical & Mailing Address List both the physical location and mailing address of the Company. 8 through 10 Self-explanatory. 11. Telephone Number. List the day time telephone number of the Company. 12. Federal ID Number Enter the Federal Employer Identification Number, or, if none, your Social Security Number. 13. Check the appropriate box that best describes the Company. 14. Category of Waste Check the appropriate box or boxes. 15. Fees Submitted Enter the total amount of fees being submitted with this application. If the applicant is a governmental entity exempt from fees pursuant to Chapter 411, Section 2(E)(3), write exempt. 16. Required Attachments The license application will not be complete without these attachments: a legible photocopy of the VEHICLE REGISTRATION (or other form if a military vehicle); a CERTIFICATE OF INSURANCE or certificate of self-insurance in accordance with 06-096 CMR 411.7; DISCLOSURE STATEMENT of the applicants history of compliance with state and federal laws and regulations relating to the handling of waste in accordance with 06-096 CMR 411.3(A)(4); and AUTHORIZATION LETTER. Completed applications must be signed, dated, and forwarded, with fees and attachments, to the Department of Environmental Protection. The top page of the multi-page form will be returned, after being stamped with the Department seal and date, as your license. For Department Use Only A. B. C. / / A. Manifest Reporting is Current B. MNHWTLID C. 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