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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS 0 DEPARTMENT OF PLANNING AND NATURAL RESOURCES ENVIRONMENTAL PROTECTION DIVISION SOLID AND HAZARDOUS WASTE PROGRAM 4611 Tutu Park Mall 45 Mars Hill, Frederiksted Suite 300, 2nd Floor St. Croix, VI 00840 St. Thomas, VI 00802 (340) 773-1082 (340) 774-3320 dpnr.vi.gov TEMPORARY DEBRIS STAGING AND REDUCTION SITE REQUEST FORM Instructions: • For information on completing this form please see the “Temporary Debris Staging and Reduction Site Form Instructions” available at: http://dpnr.vi.gov or contact the Division of Environmental Protection, Solid and Hazardous Waste Program at (340) 774-3320. • E-mail completed form with attachments to: austin.callwood@dpnr.vi.gov or send via regular mail to: Department of Planning & Natural Resources-Division of Environmental Protection, Solid and Hazardous Waste Program, 4611 Tutu Park Mall Ste 200, St. Thomas, VI 00802 Applicant Requesting Entity: ___________________________________________________________________________________________________ Mailing Address: __________________________________________________________________________________________________ District: __________________________________ Zip Code: ________________________________________________________________ Primary Contact Name: _________________________________________ Title: _________________________________________________________________ Office Phone Number: ______________________________ Ext: ___________________________________________________________ Cell phone Number: _________________________________________________________________________________________________ Email Address: ______________________________________________________________________________________________________ Proposed Location of Temporary Debris Staging and Reduction Site (TDSRS) Site Name (if appropriate): _________________________________________________________________________________________ Street Address: ____________________________________________________________________________ District: ________________ Parcel ID Number: ________________ Plot No(s): _____________________________________________________________________ Current Use of Site: __________________________________________________________________________________________________ 1. Is the property owned by the entity requesting approval? Yes No If “No”, • Provide the name of the property owner(s): Property Owner Name: • Attach a copy of the agreement between the requesting entity and the property owner allowing use of the property for a TDSRS. 2. Will other government entities be permitted to use the site? Yes No - If “Yes”, .• List the government entities that will be permitted to use the site: • Attach a shared service agreement which allows the above entities to use the site. 3. Describe security measures that will be taken to prevent unauthorized access to the site (i.e., fence, gate, police patrol, etc.): 4. Describe measures to control dust emissions (e.g., water truck, hosing, paved road, truck tarping, etc.): STORAGE AREA(S): Vegetative Debris 1. Will vegetative debris be processed on site? ______Yes ______No 2. Unprocessed Vegetative Waste Number of stockpiles: ____________ Each unprocessed waste stockpile will be: Length _________ x Width _________ x Height _________ (in feet) 3. Processed Vegetative Waste Number of stockpiles: ____________ Each processed waste stockpile will be: Length ________ x Width _________ x Height _________ (in feet) 4. Stockpile(s) will be located on: _____ Grass _____Gravel _____ Other (specify): _________________________ Construction & Demolition Debris 1. Number of stockpiles: _____________ 2. Each stockpile will be: Length _________ x Width _________ x Height _________ (in feet) 3. Stockpile(s) will be located on: ____Asphalt _____Concrete ____Grass _____Gravel ____Other (specify): ___________________ 4. Will waste be stored in containers? ____Yes ____No If “Yes”, what type of container? __________________________________________________ Number of containers: ______________ Size of containers: _______________ (yd3) Bulky Solid Waste White Goods 1. Number of stockpiles: _____________ 2. Each stockpile will be: ......... Length _________ x Width _________ x Height _________ (in feet) 3. Stockpile(s) will be located on: ____ Asphalt ___Concrete ___Other (specify): _________________________ 4. Will waste be stored in containers? ____Yes _____No If “Yes”, what type of container? __________________________________________________ Number of containers: ______________ Size of containers: ______________ (yd3) Household Hazardous Waste Note: Household Hazardous Waste must be stored in containers 1. Type of containers: _____________________________________________________________ 2. Number of containers: ______________ Size of containers: _______________ (yd3) 3. Container will be located on: ____ Asphalt ____ Concrete ____ Other (specify): ______________________ E-Waste Note: E-Waste must be stored in containers 1. Type of containers: _____________________________________________________________ 2. Number of containers: ______________ Size of containers: _______________ (yd3) 3. Container will be located on: ____ Asphalt ____ Concrete ____ Other (specify): _____________________ Municipal Solid Waste Note: Municipal Solid Waste must be stored in containers 1. Type of containers: _____________________________________________________________ 2. Number of containers: ______________ Size of containers: _______________ (yd3) 3. Container will be located on: ____ Asphalt ____ Concrete _____ Other (specify): _____________________________ ATTACHMENTS The following items must be submitted with this form: • Site Drawing – Please review the Site Drawing requirements listed in the TDSRS Instructions. • Photographs – Please submit current photographs of the site which show existing conditions. (Google Earth or other satellite images are not sufficient.) Indicate the date the photos were taken: _____________________ Note: An additional technical review of the TDSRS site will be conducted by the Department. The Department will coordinate obtaining approvals from Historic Preservation, Stormwater Management, Endangered Species, Freshwater Wetlands, Flood Hazard Areas, the Pinelands Commission (if applicable), and the Highlands Council (if applicable). Additional information may be requested. CERTIFICATIONS AND ENDORSEMENTS Note: The local fire official, the Director of the Virgin Islands Waste Management Authority or the Commissioner of Public Works, the Director of VITEMA or Office of Disaster Recovery (ODR) Office may sign off below or attach separate endorsements from each official: Certification by Executive Director of the VI Waste Management Authority or Commissioner of Public Works Supervisor, or Director of entity requesting approval “ I certify under penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information and that submitting false information may result in environmental citation. I agree to abide by the conditions stipulated in any approvals issued for the operation of this site as a TDSRS.” Signature: ______________________________________________________________ Date: ______________________ Name / Title: _________________________________________________________________________________________ Local Fire Official I have reviewed the information contained on this form and have no objections to the use of the site as a TDSRS. Signature: ______________________________________________________________ Date: ______________________ Name / Title: _________________________________________________________________________________________ Virgin Islands Territorial Emergency Management Agency (VITEMA) I have reviewed the information contained on this form and have no objections to the use of the site as a TDSRS. Signature: ______________________________________________________________ Date: ______________________ Name / Title: _________________________________________________________________________________________ Additional Information