C.M.R. 06, 096, ch. 418, app 096-418-B - TEMPLATE FOR AUTHORIZATION FORM FOR BENEFICIAL USE

use in conjunction with the requirements of the following sections of this rule:

Section 3(S)

Section 6(B)

Section 10

AUTHORIZATION FORM FOR BENEFICIAL USE

Generator of Secondary Material Beneficial Use Location

Facility Name _________________ Facility Name _______________

Street Address ______________ Street Address ________________

________________________ ___________________________

GPS Coordinates:______________________

Contact Name _______________ Contact Name _______________

Contact phone number ____________ Contact phone number __________

As the generator of the secondary material, I hereby certify that the Department of Environmental Protection has authorized the beneficial use of this secondary material through:

[] beneficial use exemption for no more than 800 tons of construction fill per parcel; or

[] DEP permit-by-rule or license number ______________________

Unless any necessary permit is obtained from the Department, this secondary material may not be placed in the following locations:

* in standing water;

* in a channeled drainage flow;

* in a protected natural resource;

* below the water table; or

* where it may wash into any water of the state.

If the Department issued a permit-by-rule or license authorizing the beneficial use of this secondary material, a copy of the document is attached. The Department license []does []does not include additional conditions for the use of this secondary material that you are required to meet.

________________________ _______________________

Signature of Generator Representative Title

________________________ _______________________

Printed Name Date

As the beneficial user of the secondary material, I hereby certify that I have received this authorization and will comply with the terms of this form and, if applicable, any relevant terms of the beneficial use license for this material. I understand that the secondary material must remain at the location specified above, and that I must either keep this form at the location where the beneficial use occurs, or at my local office for a 3 year period. I understand the form must be made available to the Department upon request.

_____________________ ____________________

Signature of Beneficial User Date

___________________

Printed Name

Notes

C.M.R. 06, 096, ch. 418, app 096-418-B