Atlantic Used Oil Management Association - Collector registration application

Collector registration application form
******* IMPORTANT NOTICE ******

Before completing the collector registration application form, please make sure you have the following documents in PDF format: Civil and Environment Insurance Certificate, Government issued Operation permit(s) and completed, signed and initialed Collector Agreement(s). A separate Collector Agreement is required for each province for which you seek registration as a collector. The Collector Agreements are available on the "Collector" tab of our website's "Partners" page. All above mentioned documents must be attached to the collector registration form.
Company legal name:*
Address*

Street address

Street address (line 2)

City Province/State

Postal/Zip code
Telephone number to display on website*

Area codePhone #
Extension (if any)

Contact Person*
Title*
Contact person email address*
Contact telephone number*

Area codePhone #
Extension (if any)
Contact person for RI claims (if different)
Email address for RI claims contact person (if different)
RI claims contact telephone number

Area codePhone #
Extension (if any)

Which of the following provinces will you be collecting Atlantic Used Oil Management Association products in?*

New BrunswickNewfoundland & LabradorNova ScotiaPrince Edward Island
Important: You are required to register as a collector for each province where you will offer your collection services.

Please indicate the address of your facility(ies) where Atlantic Used Oil Management Association products are being or will be stored. (List all addresses that apply)*
Do you have a permit, certificate or approval for the facility(ies) listed above, where Atlantic Used Oil Management Association products are or will be stored?*

YesNo
Attach all government issued permit(s), certificate(s) or approval(s) for each aforementionned facility(ies) where Atlantic Used Oil Management Association products are or will be stored.*

Attach your file(s)
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For each location, briefly explain what the provincial or federal requirements are in order to collect and store the products for which you are registering with Atlantic Used Oil Management Association.*
For any of your locations, are you required to produce a report to local government authorities having jurisdiction where your waste storage facility(ies) is located, or where your operations occur?*

YesNo
For each facility, specify which type(s) of report(s), and the frequency at which you are required to produce such report(s).*

For each facility, briefly describe your current spill prevention and containment measures (e.g. berm(s) or other confinement unit(s), regular inspections of storage units, proximity of absorbants, etc.)*
Calculation*
What control have you implemented to determine your collected products' province of origin in order to notify processors of volumes received from each province (or state)? If your procedure differs per product, explain the differences?*
Keep in mind that you will be required to provide accurate provincial volume inventories and reports in order to complete your collector claim forms and to complete annual statements with each provincial Atlantic Used Oil Management Association.

For each aforementionned facility, when was the last inspection in regards to activities for which you are registering with Atlantic Used Oil Management Association by the local government authority? Specify the location of the inspected facility(ies), the month and year of inspection.*
Over the last two years, has your company received any infraction notice from local government authorities regarding a facility whose activities are related to Atlantic Used Oil Management Association products?*

YesNo
Attach a copy of your infraction notice(s).*

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For each infraction notice your company has received, briefly explain what measures were implemented to correct the situation. *

Each provincial Atlantic Used Oil Management Association registration requires its own signed and initialized Collector Agreement. All provincial Collector Agreements are available on their respective provincial program's website, in the "Collector" tab of the "Partners" page.
Please attach your signed and initialized NB Collector Agreement below.*

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Please attach your signed and initialized NL Collector Agreement below.*

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Please attach your signed and initialized NS Collector Agreement below.*

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Please attach your signed and initialized PE Collector Agreement below.*

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Attach any civil and environmental insurance certificate relevant to activities for which you are registering with Atlantic Used Oil Management Association.*

Attach your file(s)
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Which of the following products do you wish to register as a Atlantic Used Oil Management Association collector for? Select all products which you intend to collect in at least one province.*

USED OILUSED ANTIFREEZE (GLYCOL)USED FILTERSUSED OIL, ANTIFREEZE AND DIESEL EXHAUST FLUID* CONTAINERS**USED AEROSOL CONTAINERS***
*Diesel exhaust fluid containers are not applicable in Newfoundland & Labrador.

**Regulated container sizes eligible for collection incentives go up to 250L in New Brunswick and Prince Edward Island. In Newfoundland & Labrador and Nova Scotia, regulated container sizes eligible for collection incentives are limited to 50L and less.

***In Newfoundland & Labrador, only lubricants and break cleaner aerosol containers are applicable. In New Brunswick, Prince Edward Island and Nova Scotia, lubricants and automotive parts cleaner aerosol containers are applicable.

Which of these provinces will you be collecting USED OIL in?*

New BrunswickNewfoundland & LabradorNova ScotiaPrince Edward Island
Collection of USED OIL: Estimated annual volume (in L)*
How long has your company been collecting USED OIL?*
List the address of each facility where you store USED OIL and specify the maximum storage capacity for each facility.*
How many tanks do you have at each address to store your recovered USED OIL? Indicate the volume of each of them.*
How many trucks does your company have to collect USED OIL?*
For each of your trucks collecting USED OIL, provide the following information:*
What are steps of your collection and storage process and how do you keep track of the USED OIL quantities collected at each generators location? If the process varies by province or location, please specify how.*
Do you exercise quality control of the USED OIL collected?*

YesNo
Briefly explain your quality control procedures for the USED OIL collected in each province.*
Are USED OIL analysis performed by an accredited laboratory?*

YesNo
Where do you dispose of oily water?*

Which of these provinces will you be collecting USED ANTIFREEZE in?*

New BrunswickNewfoundland & LabradorNova ScotiaPrince Edward Island
Collection of USED ANTIFREEZE: Estimated annual volume (in L)*
How long has your company been collecting USED ANTIFREEZE?*
List the address of each facility where you store USED ANTIFREEZE and specify the maximum storage capacity for each facility.*
How many tanks do you have at each address to store your recovered USED ANTIFREEZE? Indicate the volume of each of them.*
How many trucks does your company have to collect USED ANTIFREEZE?*
For each of your trucks collecting USED ANTIFREEZE, provide the following information:*
What are steps of your collection and storage process and how do you keep track of the USED ANTIFREEZE quantities collected at each generators location? If the process varies by province or location, please specify how.*
Do you exercise quality control of the USED ANTIFREEZE collected?*

YesNo
Briefly explain your quality control procedures for the USED ANTIFREEZE collected in each province.*
Do your truck drivers use a refractometer at every colleciton?*

YesNo

What method will you use to proceed with the payment of the registration fee ($200 plus taxes per provincial collector registration)?*

ChequeElectronic funds transfer (EFT)
Please take note of the following information in order to successfully submit your payment for the registration fees. Please address your cheque at the attention of:

UOMA Atlantic
8005 Blvd. Du Quartier, Suite 303
Brossard, QC, Canada
J4Y 0N5
You can download a copy of UOMA Atlantic's void cheque here to obtain the information necessary to issue your payment of the registration fee via electronic funds transfer.
Would you like to receive payments by cheque or electronic funds transfer (EFT)?*

ChequeEFT
Please attach a void cheque in order to get EFT*

Attach your file

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Signatory Name*
Signatory title*
I, {signatoryName}, {signatoryTitle}, declare I am duly authorized for this purpose and certify that the information provided on this form is accurate.
Signature*

Clear
Signature*

I confirm this signature
Date*

an MoisJour
Date
Should be Empty:

Collector registration application form