W. Va. Code R. agency 33, tit. 33, ser. 33-06, app A

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Current through Register Vol. XLI, No. 50, December 13, 2024

Appendix A

WEST VIRGINIA DIVISION OF ENVIRONMENTAL PROTECTION

SOLID WASTE ASSESSMENT FEE EXEMPTION APPLICATION

PLEASE COMPLETE AND RETURN TO:

W. Va. Division of Environmental Protection

Assessment Fee Exemption

1356 Hansford Street

Charleston, WV 25301

1. NAME, ADDRESS, AND TELEPHONE NUMBER OF APPLICANT:

_____________________________________________________

Please indicate whether you are the:

()Facility owner,

()Facility operator,

()Facility lessee,

()Person delivering his or her waste to a resource recovery; or

()Recycling facility.

2. LOCATION OF THE FACILITY AND ITS PERMIT NUMBER:

_____________________________________________________

3. BRIEF DESCRIPTION OF THE TYPE AND ESTIMATED ANNUAL AMOUNT OF WASTE DISPOSED AT THIS FACILITY:

_____________________________________________________

4. BRIEF DESCRIPTION OF THE BUSINESSES OR ACTIVITIES WHICH GENERATE THE WASTE DISPOSED AT THIS FACILITY:

_____________________________________________________

NOTE: If you are seeking an exemption for a facility that disposes of waste on a cost-sharing or nonprofit basis, please complete item 5. If you are seeking an exemption for reuse or recycling, please complete item 6.

5. BRIEF SUMMARY OF THE LEGAL DOCUMENTS WHICH DESCRIBE THE RELATIONSHIP BETWEEN YOUR FACILITY AND THE INDIVIDUALS DISPOSING WASTE THERE ON A COST-SHARING OR NONPROFIT BASIS:

_____________________________________________________

Please attach an additional sheet listing the name, address, and telephone number of each person using the facility on a cost-sharing or nonprofit basis.

6. BRIEF DESCRIPTION OF THE PROCESS OR METHOD EMPLOYED TO REUSE OR RECYCLE YOUR DELIVERED WASTE:

_____________________________________________________

Please attach a notarized statement from the facility owner or operator that certifies that a reuse or recycling process is in operation at his or her facility and that the delivered waste will in fact be reused or recycled.

I hereby declare that the information in this application is accurate and true to the best of my knowledge and belief. I understand that the filing of false, inaccurate, or misleading information is grounds for the revocation of my exemption.

______________________ _____________________

Signature of Applicant Date

W. Va. Code R. agency 33, tit. 33, ser. 33-06, app A