New Brunswick-Collector registration application form

Collector registration application form

New Brunswick
******* IMPORTANT NOTICE ******

Before completing the collectors registration application form, please make sure you have completed, signed and initialed each page of the Collectors Agreement and that you have the following documents in PDF format: the initialed Collectors Agreement, your Civil and Environment Insurance Certificate and Government issued Operation permit(s) (if applicable). All above mentioned documents must be attached to the following collectors registration form.
Company legal name:*
Address*

Street address

Street address (line 2)

City Province/State

Postal/Zip Code
Telephone*

Area CodePhone #
Extension

Contact Person*
Title*
Contact person email address*

Confirmation EmailConfirm contact person's email Address
Contact person for RI claims (if different)
Email address for RI claims contact person (if different)

Confirmation EmailConfirm email address for RI claims contact person

Where are your storage facilities located? (select all that applies)*

In New BrunswickOutside of New Brunswick

Please indicate the address of your hazardous waste storage facility(ies) in New Brunswick where will be stored Atlantic Used Oil Management Association (New Brunswick) products.*
Do you have a permit or certificate for your New Brunswick facility(ies) where you store products for which you are registering with Atlantic Used Oil Management Association (New Brunswick)?*

YesNo
Attach your government issued permit(s) or certificate(s) for every facility(ies) where will to stored Atlantic Used Oil Management Association (New Brunswick) products*

Attach your file(s)
You can attach more than one file Cancelof
Are you required to produce a report to the government authority having jurisdiction in New Brunswick for your hazardous waste storage facility(ies) in New Brunswick?*

YesNo
Specify which type(s) of report(s), for which facility(ies), and the frequency at which you are required to produce such report(s).*

Please indicate the address of every hazardous waste storage facility(ies) outside of New Brunswick where you will store Atlantic Used Oil Management Association (New Brunswick) products.*
For every facility(ies) outisde of New Brunswick, briefly explain what are the province or state requirements in order to collect/store the products for which you are registering with Atlantic Used Oil Management Association (New Brunswick).*
Do you have a permit or certificate for your facility(ies) outside of New Brunswick where you store products for which you are registering with Atlantic Used Oil Management Association (New Brunswick)?*

YesNo
Attach your government issued permit(s) or certificate(s) for every facility(ies) where you intend to store Atlantic Used Oil Management Association (New Brunswick) products.*

Attach your file(s)
You can attach more than one file Cancelof
Are you required to produce a report to local government authorities for your hazardous waste storage facility(ies) outside of New Brunswick?*

YesNo
Specify which type(s) of report(s), for which facility(ies), and the frequency at which you are required to produce such report(s).*

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.)*
When was your last inspection by the government authority having jurisdiction in New Brunswick (or the equivalent government authority if you are located outside the province of New Brunswick) concerning the activities for which you are registering with Atlantic Used Oil Management Association (New Brunswick)? Specify the location of the inspected facility(ies), the month and year of inspection.*
Over the last two years, has your company received an infraction notice from the government authority having jurisdiction in New Brunswick (or the equivalent government autority if you are located outside of New Brunswick) regarding a facility whose activities are related to Atlantic Used Oil Management Association (New Brunswick) products?*

YesNo
Attach a copy of your infraction notice.*

Attach your file(s)
You can attach more than one file Cancelof
For each infraction notice your company has received, briefly explain what measures were implemented to correct the situation. *

Please select the zones in which you collect our products*

1 (Kings, Queen, St-John, Sunbury, Westmorland, York)2 (Kent)3 (Northumberland)4 (Carleton, Gloucester, Madawaska, Restigouche, Victoria)5 (Albert)6 (Charlotte)7 (Deer Island, Campobello Island, Grand Manan Island)

Collector's Agreement signed and initialized on every page*

Attach your file

Cancelof
Civil and environmental insurance certificate.*

Attach your file(s)
You can attach more than one file Cancelof

Which of the following products do you wish to register as a Atlantic Used Oil Management Association (New Brunswick) collector for?*

USED OILSUSED ANTIFREEZEUSED FILTERSUSED OIL AND ANTIFREEZE CONTAINERSUSED AEROSOL CONTAINERS (lubricants and brake cleaners only)

Collection of USED OILS: Estimated annual volume (in L)*
How long has your company been collecting USED OILS?*
List the address of each facility where you store USED OILS and specify the maximum storage capacity for each facility.*
How many tanks does your company have to store collected USED OILS? Indicate the capacity for each one.*
How many trucks does your company have to collect USED OILS?*
For each of your trucks collecting USED OILS, provide the following information:*
What are steps of your collection process and how do you keep track of the USED OILS quantities collected at each generators location?*
Do you exercise quality control of the USED OILS collected?*

YesNo
Briefly explain your quality control procedures for the USED OILS collected.*
Are USED OILS analysis performed by an accredited laboratory? (Atlantic Used Oil Management Association (New Brunswick) requires analysis performed by accredited laboratory).*

YesNo
Where do you dispose of oily water?*

On the premisesAt another facility
Indicate the name of the establishment where you dispose of your oily water.*
Are you collecting USED OILS applicable to Atlantic Used Oil Management Association (New Brunswick)'s program in other provinces than New-Brunswick?*

YesNo
What control will you implement in order to determine what qualifies as Atlantic Used Oil Management Association (New Brunswick) and NON-Atlantic Used Oil Management Association (New Brunswick) products amongst the quantities collected?*

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 does your company have to store collected USED ANTIFREEZE? Indicate the capacity for each one.*
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 process and how do you keep track of the USED ANTIFREEZE quantities collected at each generators location?*
Do you exercise quality control of the USED ANTIFREEZE collected?*

YesNo
What are steps of your collection process and how do you keep track of the USED ANTIFREEZE quantities collected at each generators location?*
Do your truck drivers use a refractometer at every colleciton?*

YesNo
Are you collecting USED ANTIFREEZES applicable to Atlantic Used Oil Management Association (New Brunswick)'s program in other provinces than New-Brunswick?*

YesNo
What control will you implement in order to determine what qualifies as Atlantic Used Oil Management Association (New Brunswick) and NON-Atlantic Used Oil Management Association (New Brunswick) products amongst the quantities collected?*

Collection of USED FILTERS: Estimated annual volume (in kg)*
How long has your company been collecting USED FILTERS?*
List the address of each facility where you store USED FILTERS and specify the maximum storage capacity for each facility.*
How many trucks does your company have to collect USED FILTERS?*
For each of your trucks collecting USED FILTERS, provide the following information:*
What are steps of your collection process and how do you keep track of the USED FILTERS quantities collected at each generators location?*
What type of containers do you collect at your generator's location for USED FILTERS? (select all that applies)*

205L drums240L wheeled bins360L wheeled bins
Do you have a scale to weigh the USED FILTERS containers you've collected?*

YesNo
When was your last weighing scale calibration?*
Indicate the date (YYYY-MM-DD )
Products applicable to Atlantic Used Oil Management Association (New Brunswick)'s program originating from other provinces are NON-Atlantic Used Oil Management Association (New Brunswick) products.
Are you collecting USED FILTERS applicable to Atlantic Used Oil Management Association (New Brunswick)'s program in other provinces than New-Brunswick?*

YesNo
What control will you implement in order to determine what qualifies as Atlantic Used Oil Management Association (New Brunswick) and NON-Atlantic Used Oil Management Association (New Brunswick) products amongst the quantities collected?*

Collection of USED OIL AND ANTIFREEZE CONTAINERS: Estimated annual volume (in kg)*
How long has your company been collecting USED OIL AND ANTIFREEZE CONTAINERS?*
List the address of each facility where you store USED OIL AND ANTIFREEZE CONTAINERS and specify the maximum storage capacity for each facility.*
How many trucks does your company have to collect USED OIL AND ANTIFREEZE CONTAINERS?*
For each of your trucks collecting USED OIL AND ANTIFREEZE CONTAINERS, provide the following information:*
What are steps of your collection process and how do you keep track of the USED OIL AND ANTIFREEZE CONTAINERS quantities collected at each generators location?*
What type of containers do you collect at your generator's location for USED OIL AND ANTIFREEZE CONTAINERS? (select all that applies)*

205L drums240L wheeled bins360L wheeled bins
Do you have a scale to weigh the USED OIL AND ANTIFREEZE CONTAINERS containers you've collected?*

YesNo
When was your last weighing scale calibration?*
Indicate the date (YYYY-MM-DD )
Are you collecting USED OIL AND ANTIFREEZE CONTAINERS applicable to Atlantic Used Oil Management Association (New Brunswick)'s program in other provinces than New-Brunswick?*

YesNo
What control will you implement in order to determine what qualifies as Atlantic Used Oil Management Association (New Brunswick) and NON-Atlantic Used Oil Management Association (New Brunswick) products amongst the quantities collected?*

Collection of USED AEROSOL CONTAINERS (lubricants and brake cleaners only): Estimated annual volume (in kg)*
How long has your company been collecting USED AEROSOL CONTAINERS (lubricants and brake cleaners only)?*
List the address of each facility where you store USED AEROSOL CONTAINERS (lubricants and brake cleaners only) and specify the maximum storage capacity for each facility.*
How many trucks does your company have to collect USED AEROSOL CONTAINERS (lubricants and brake cleaners only)*
For each of your trucks collecting USED AEROSOL CONTAINERS (lubricants and brake cleaners only), provide the following information:*
What are steps of your collection process and how do you keep track of the USED AEROSOL CONTAINERS (lubricants and brake cleaners only) quantities collected at each generators location?*
What type of containers do you collect at your generator's location for USED AEROSOL CONTAINERS (lubricants and brake cleaners only)? (select all that applies)*

205L drum240L wheeled bins360L wheeled bins
Do you have a scale to weigh the USED AEROSOL CONTAINERS (lubricants and brake cleaners only) containers you've collected?*

YesNo
When was your last weighing scale calibration?*
Indicate the date (YYYY-MM-DD)
Are you collecting USED AEROSOL CONTAINERS applicable to Atlantic Used Oil Management Association (New Brunswick)'s program in other provinces than New-Brunswick?*

YesNo
What control will you implement in order to determine what qualifies as Atlantic Used Oil Management Association (New Brunswick) and NON-Atlantic Used Oil Management Association (New Brunswick) products amongst the quantities collected?*

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

ChequeElectronic funds transfer (EFT)
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

Cancelof
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
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