Del. Admin. Code tit. 1, 500, 501, att. A

Current through Register Vol. 28, No. 5, November 1, 2024

Attachment A

To: Delaware Solid Waste Authority

P.O. Box 455

Dover, DE 19903-0455

I hereby apply for a Solid Waste Collectors License for the period of July1, 20___ through June 30, 20___ in accordance with the Regulations of the Delaware Solid Waste Authority. Accordingly, the following is submitted: Note: This application will not be processed unless all requested information is provided and deemed complete including;

Proof of insurance as required by section 3.04;

Minimum Bond or Surety, as required by Section 3.10; and,

A copy of your Delaware Business License.

1. Applicant: (Individual or Firm Name)

2. Doing business as: (name to appear on License)

3. Business Office Information: (one phone number must be a Delaware number) OFFICE A:

__________________________________________________________________________________________

Street Area code - Phone number

__________________________________________________________________________________________

City State Zip Code

__________________________________________________________________________________________

Name of Individual having administrative responsibility at this location

OFFICE B:

_______________________________________________________________________________

Street Area code - Phone number

_________________________________________________________________________________________

City State Zip Code

_________________________________________________________________________________________

Name of Individual having administrative responsibility at this location

4. Answering service if applicable:

_________________________________________________________________________________________

Name of service

_________________________________________________________________________________________

Street Area code - Phone number

_________________________________________________________________________________________

City State Zip Code

_____________________________________________________________________________

Name of Individual having administrative responsibility at this location

5. Registered Agents or Authorized Representatives:

______________________________________________________________________________

Name

_________________________________________________________________________________________

Street Area code - Phone number

_________________________________________________________________________________________

City State Zip Code

______________________________________________________________________________

Name

_________________________________________________________________________________________

Street Area code - Phone number

_________________________________________________________________________________________

City State Zip Code

6 . Type of business : £ Sole Proprietorship £ Partnership £ Municipality £ Corporation *

* If Non-Delaware Corporation, provide proof of Delaware Registration

7. Date business was established:

8. Delaware Business License number: (contact Division of Revenue)

9. DNREC Waste Haulers License number:

10. Federal Taxpayer Identification number:

11. Owners or partners in unincorporated business. Indicate percentage of ownership:

Name Percentage

Street City State Zip Code

B:_____________________________________________________________________

Name Percentage

Street City State Zip Code

C: _____________________________________________________________________

Name Percentage

Street City State Zip Code

12. Officers, Directors, Shareholders holding in excess of 10% of issued Stock in incorporated business:

A: ___________________________________________________________________________

Name Percentage

___________________________________________________________________________

Street City State Zip Code

B: ___________________________________________________________________________

Name Percentage

___________________________________________________________________________

Street City State Zip Code

C: ___________________________________________________________________________

Name Percentage

___________________________________________________________________________

Street City State Zip Code

13. Indicate if any partnership or corporation other than applicant has any interest, direct or indirect, in the License applied for, or in the business conducted under such License. (If so, state names, addresses, and interest of the partnerships, corporations, and principals involved, indicating the nature and extent of the interest.)

£ Not applicable £ Applicable, provide details:

___________________________________________________________________________

14. Indicate if any individual, partnership or corporation other than applicant receives or will receive (by way of rent, salary, or otherwise) all or any portion of percentage of the gross or net profits or income derived from business conducted under License applied for:

£ Not applicable £ Applicable, provide details:

___________________________________________________________________________

15. Indicate if your company or parent company has ever been convicted of civil or criminal offenses concerning waste transporting, processing, or disposal.

£ No £ Yes (Provide details: Use the back of this sheet or separate sheet if necessary)

16. Indicate if the applicant, any person mentioned in this application, or any person having a beneficial interest in the application has ever been denied a License to collect solid waste.

£ Not applicable £ Applicable, provide details:

___________________________________________________________________________

17. State general area served by applicant:

___________________________________________________________________________

18. Indicate days of the week collections are made:

£ Mon £ Tue £ Wed £ Thu £ Fri £ Sat £ Sun

19. Daily average weight of Household solid waste collected: ______________________________ Tons

20. Daily average weight of Municipal solid waste collected: ______________________________ Tons

21. Daily average weight of Commercial/Industrial solid waste collected: ___________________ Tons

22. Other solid waste collected: Tons.

23. Indicate location(s) where solid waste is being or will be delivered:

Type of Waste

Location Delivered

24. Statement of experience in solid waste collection, transportation, and/or disposal:

___________________________________________________________________________

25. Consent to inspections:

The applicant hereby agrees and consents to the inspection at any time or place, by any employee of the Delaware Solid Waste Authority who presents identification of his/her status as an employee of DSWA, of any vehicle owned or operated on behalf of the applicant which displays a License Sticker issued by DSWA. Unless otherwise prohibited by law, the applicant also hereby agrees and consents to the inspection, by any employee of DSWA, of any container used for the deposit of any material which the applicant may transport with a vehicle which displays a License Sticker issued by DSWA.

I HEREBY CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHED HERETO IS TRUE AND CORRECT AND THAT I HAVE READ AND AM FAMILIAR WITH THE REQUIREMENTS OF THE REGULATIONS OF THE DELAWARE SOLID WASTE AUTHORITY.

I SPECIFICALLY UNDERSTAND AND AGREE TO BE BOUND BY SECTION 4.01, IF APPLICABLE, WHICH REQUIRES CONTRACTORS WHO COLLECT OR HAUL SOLID WASTE PURSUANT TO A CONTRACT WITH A MUNICIPALITY (INCLUDING TOWNS, CITIES, COUNTIES, STATE AGENCIES, ETC.) TO DELIVER SUCH SOLID WASTE TO A DSWA FACILITY.

_______________ ______________________________________ _____________________________

Date Signature of Applicant Title

_______________________________________________

Printed or typed name of Applicant

STATE OF ________________________________ COUNTY OF ____________________________________

Before me appeared ________________________________, who under oath certifies that the information

Print Name

provided in this application is true and correct.

________________ ____________________________________________________

Date Notary Public

Del. Admin. Code tit. 1, 500, 501, att. A

17 DE Reg. 313 (9/1/2013)(Final)