VSQG waste collection facility annual recertification

Activity year *

Facility name *

EPA ID# *

Location address *

City *

State *

Zip code *

Check if your mailing address in the same as above

Yes

Mailing address

Mailing city

State

Zip code

Check box if updated

Yes

Contact name *

Contact email *

Contact phone *

Facility owner *

County *

Facility operator (If different from above)

Complete the certification below. If you would like a variance from any of the requirements as stated in the regulations, policy, or guidance, describe below and give reason. Do not include variances already given for your facility. A variance is not in effect until you receive written authorization from the department. (Max 950 characters.) *

0/950 characters

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name, title and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form bears the same rights and responsibilities as a hand-signed form.

I certify that:

1. This facility is in compliance with the requirements for Large Quantity Generators except as modified by the VSQG Waste Collection Facility Policy including, but not limited to: *

a. The Waste Management requirements as described in the VSQG Waste Collection Facility Guidance.

b. The Preparedness/Prevention and Training requirements as described in the VSQG Waste Collection Facility Guidance.

c. The Contingency Plan and Closure Plan requirements as described in the VSQG Waste Collection Facility Guidance.

2. The information contained in this submittal is, to the best of my knowledge, true, accurate and complete in all respects; and

3. I am fully authorized to make this certification on behalf of this facility.

I am aware that there are significant penalties including, but not limited to, possible fines and imprisonment for willfully submitting false, inaccurate or incomplete information.

Facility representative *

Title *

Date * +

If you would like an email confirming that your completed form was received, please enter your email address:

Select the Submit button to send your form to the department. You will receive an email confirmation that we received your form. Your authorization request is not complete until you SUBMIT your data.