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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: _