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NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION-DIVISION OF SOLID AND HAZARDOUS WASTE

SOLID WASTE ORIGIN AND DISPOSAL FORM

A. Transporter Section (To be completed by the Transporter prior to transport to the disposal site)

1. Name of Registered Transporter: ______________________________________ Phone No. ____________________ 2. NJDEP Registration No.: __________________

Type of Transporter Registration: (Check One)

A-901 Licensed

Registered self-generator

Registration Exempt

Waste Self- Generated: (Check One)

YES

5. Name of LESSOR if the solid waste vehicle is leased: ________________________________________________________

6. Decal No.

Type

License Plate No.

Capacity

Leased – Yes or No

7. A. Waste Types (Please circle)

ID 10 ID 13 ID 13C ID 23

______________

Cab or Single Unit

________________

___________

________________

ID 25 ID 27 ID 27A ID 27I

Other:__________________

______________

Container

______N/A_______

___________

________________

B. Source Separated Recyclables: (Please circle)

Paper / Corrugated / Glass / Metal / Plastics

______________

Trailer

________________

___________

________________

Concrete / Asphalt / Wood / Yard Material

8. Transporter to complete waste origin information.

Other: __________________________________

Municipality (ies)

County(ies)

State

% of Total Load

_______________________

____________________

_______

____________________ * Sending Facility: (If solid waste is transported

from a solid waste intermodal, transfer, or material

_______________________

____________________

_______

____________________ recovery facility, list the facility name in the

Municipality column, ID # in the County column

_______________________

____________________

_______

____________________ and the State in which the sending facility is

located in the State column.)

___________________

_________________

______

_________________

9. Date Waste Collected: ________________

10. Transporter’ s Certification:

I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.

_____________________________

_________________________

______________

PRINT DRIVER’ S NAME

SIGNATURE

DATE

B. Disposal Destinations

11. Final Disposal Facility Name & State (Transporter Completes 11 & 12): ________________________________________________________________________________

12. Non Hazardous Manifest # or Bill of Lading # or Pull Ticket #: ______________________________

13. In State weigh location (Weigh master completes 13 through 16): ____________________________________________________________________________________

14. GROSS WT.:___________________ NET WT.

:____________________

. SCALE TICKET No.

:_________________

(IN STATE DISPOSAL ONLY)

16. Weigh master’ s Certification:

I CERTIFY THAT THIS FORM HAS BEEN COMPLETED BY THE REGISTERED TRANSPORTER IDENTIFIED ABOVE, AND THAT THE GROSS WEIGHT FIGURE IS TRUE AND

ACCURATE FOR LOADS GOING OUT OF STATE.

SIGNATURE:____________________________________

DATE:___________________

C. In State Disposal Facility Section (To be completed by facility operator for loads disposed of in State only)

17. New Jersey Receiving Facility Operator Certification: