GOVERNMENT
OF THE VIRGIN ISLANDS OF THE UNITED STATES
DEPARTMENT
OF PLANNING
AND NATURAL
RESOURCES
DIVISION
OF ENVIRONMENTAL
PROTECTION
45 MARS HILL
FREDERIKSTED,
ST. CROIX, VI 00840
PHONE: (340) 773-1082, FAX: (340) 773-9310
HAZARDOUS WASTE TRANSPORTATION APPLICATION
Name of Business: ------------------------------
Type of Business:
_
Tax Assessor's ID Number: -----------------------
EPA ID Number:-------------------------------
All transporters of hazardous waste must provide adequate financial responsibility with
respect to the transportation of hazardous waste. The financial responsibility required
shall be adequate to cover the costs of spills, clean-up and remediation of the
environment and injury to any person as a result of any incident that may occur during
the transportation and storage of hazardous waste. Proof of financial responsibility may
be similar to that which is provided for in Title 12 Section 714 of the Virgin Islands
Code. Please attach a copy of the required bond or insurance policy.
Business License Number: ------------------------
OWNER OF BUSINESS:
_
Name:
__
Mailing Address:.
_
Physical Address:
_
FINANCIAL RESPONSIBILITY:
HAZARDOUS WASTE TRANSPORTATION
APPLICATION
NAMEOFCOMPANY:
~~~~
Page 2 of4
BUSINESS OPERATION:
Telephone/FAX Nos:
_
On-Site Managers & Operators of Facility:
_
DucyHours:,
___
Emergency Contact(s):
_
Physical Address:
_
Emergency Telephone No(s)/Beeper No(s):
_
Hours of Operation of the Facility:
_
Will any truck(s) stored with hazardous waste be located in the 1st tier of the coastal
zone?
(yes or no)
If this storage area is located within the 1st tier of the coastal zone, then both secondary
containment and proof of financial responsibility is required. Please attach diagram and
description of secondary containment.
If yes does applicant hold the requisite DPNR and RCRA storage permits? _
(yes or
no)
Will the applicant hold a hazardous waste for more than ten (10) days at their facility?
__
(yes or no)
If yes please attach a copy of each.
CORPORATE
OFFICIALS:
Resident Agent:
_
Address:
_
HAZARDOUS
WASTE TRANSPORTATION
APPLICATION
NAME OF COMPANY: ------------~~~~
Page 3 of4
President:--------------------------------
Address:-------------------------------------
Secretary:
_
Address:-------------------------------------
DESCRIPTION
OF TANKERITRUCK{S)
USED TO TRANSPORT
HAZARDOUS
WASTE:
1. Make/Model/Year:----------------------------
Vehicle Identification Number(VIN): ----------------
License Plate Number:----------------------------
2. Make/ModellYear:-----------------------------
Vehicle Identification Number(VIN):
___
License Plate Number:----------------------------
TRUCK
AND FACILITY
REQUIREMENTS:
The transporter must keep the manifest with the hazardous waste at all times for
inspection by territorial and/or federal authorities. All entries must be made consistent
territorial and federal law. Please attach a copy of the manifest to be utilized in the
transporting of hazardous waste.
List separately all spill containment and cleanup equipment and supplies that are
available at the location where the truck(s) is stored and that which is available on the
truck(s) while transporting hazardous waste.
Attach a Spill Prevention, Containment and Response Plan. This plan shall include the
procedure the applicant will utilize in order to satisfy all reporting requirements in the
event of an accidental spill or discharge. Please attach copies of all reporting forms to be
used.
Hazardous waste may only be transported to other transporters or disposal facilities
which are in compliance with territorial and federal law. Please supply the following
information with respect to the hazardous waste destination(s):
HAZARDOUS WASTE TRANSPORTATION
APPLICA nON
NAME OF COMPANY:
-=---:--::-:-
Page 4 of4
1.Name of facility:
Address:-----------------
EPAlDPNR Permit No.:------------
2. Name of facility:
_
Address:---------------
EPAlDPNR Permit No.:-----------
Name of Applicant (please print):
_
Title:------------------
APPLICANT HEREBY CERTIFIES THAT HE HAS READ THE COMPLETED
APPLICATION AND THAT THE INFORMATIONFURNISHED AND CONTAINED
HEREIN IS TRUE AND CORRECT: APPLICANT FURTHER CERTIFIES THAT HE
WILL ABIDE BY ALL PROVISIONS OF THE PERMIT WHICH MAY BE ISSUED
AS A RESULT OF SUBMITTING THIS APPLICATIONFOR PROCESSING.
Signature of Applicant: (If applicant is a corporate officer who is
signing on behalf of a corporation please attach appropriate corporate resolution
authorizing same)
Sworn to and subscribed before me
this
day of
, 2(1"
Notary Public:
_
Commission Expires:
_