NB-Collector registration application form

UOMA NB - Collector registration application form
******* IMPORTANT NOTICE TO READ BEFORE FILLING THE FORM *****

Before filling the collectors registration application form, please make sure you have completed, signed and initialized every page of your Collectors Agreement and that you have the following documents in PDF format: said Collectors Agreement, your Civil and environment insurance certificate and the 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	Country

Telephone *

- Area Code Phone #
Extension

Contact Person *
Title *
Contact person email address *

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

Confirmation Email Confirm email address for RI claims contact person

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

In New Brunswick Outside of New Brunswick

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

Yes No
Attach your government issued permit(s) or certificate(s) for every facility(ies) where will to stored UOMA NB products *

Attach your file(s)
You can attach more than one file Cancel of
Are you required to produce a report to Department of Environment and Local Government for your hazardous waste storage facility(ies) in New Brunswick? *

Yes No
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 UOMA NB 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 UOMA NB. *
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 UOMA NB? *

Yes No
Attach your government issued permit(s) or certificate(s) for every facility(ies) where you intend to store UOMA NB products. *

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

Yes No
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 Department of Environment and Local Government (or the equivalent government authority if you are located outside the province of New Brunswick) concerning the activities for which you are registering with UOMA NB? 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 Department of Environment and Local Government (or the equivalent government autority if you are located outside of New Brunswick) regarding a facility whose activities are related to UOMA NB products? *

Yes No
Attach a copy of your infraction notice. *

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

Zones of operation: *

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

Collector's Agreement signed and initialized on every page *

Attach your file

Cancel of
Civil and environmental insurance certificate. *

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

Which of the following products do you wish to register as a UOMA NB collector for? *

USED OILS USED ANTIFREEZE USED FILTERS USED OIL AND ANTIFREEZE CONTAINERS USED 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? *

Yes No
Briefly explain your quality control procedures for the USED OILS collected. *
Are USED OILS analysis performed by an accredited laboratory? (UOMA NB requires analysis performed by accredited laboratory). *

Yes No
Where do you dispose of oily water? *

On the premises At another facility
Indicate the name of the establishment where you dispose of your oily water. *
Products applicable to UOMA NB's program originating from other provinces are NON-UOMA NB products.
Are you collecting USED OILS applicable to UOMA NB's program in other provinces than New-Brunswick? *

Yes No
What control will you implement in order to determine what qualifies as UOMA NB and NON-UOMA NB products amongst the quantities collected? *
You will need that information in order to complete your collector claim forms and to complete your UOMA NB annual statement.

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? *

Yes No
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? *

Yes No
Products applicable to UOMA NB's program originating from other provinces are NON-UOMA NB products.
Are you collecting USED ANTIFREEZES applicable to UOMA NB's program in other provinces than New-Brunswick? *

Yes No
What control will you implement in order to determine what qualifies as UOMA NB and NON-UOMA NB products amongst the quantities collected? *
You will need that information in order to complete your collector claim forms and to complete your UOMA NB annual statement.

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 drums 240L wheeled bins 360L wheeled bins
Do you have a scale to weigh the USED FILTERS containers you've collected? *

Yes No
When was your last weighing scale calibration? *
Indicate the date (YYYY-MM-DD )
Products applicable to UOMA NB's program originating from other provinces are NON-UOMA NB products.
Are you collecting USED FILTERS applicable to UOMA NB's program in other provinces than New-Brunswick? *

Yes No
What control will you implement in order to determine what qualifies as UOMA NB and NON-UOMA NB products amongst the quantities collected? *
You will need that information in order to complete your collector claim forms and to complete your UOMA NB annual statement.

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 drums 240L wheeled bins 360L wheeled bins
Do you have a scale to weigh the USED OIL AND ANTIFREEZE CONTAINERS containers you've collected? *

Yes No
When was your last weighing scale calibration? *
Indicate the date (YYYY-MM-DD )
Products applicable to UOMA NB's program originating from other provinces are NON-UOMA NB products.
Are you collecting USED OIL AND ANTIFREEZE CONTAINERS applicable to UOMA NB's program in other provinces than New-Brunswick? *

Yes No
What control will you implement in order to determine what qualifies as UOMA NB and NON-UOMA NB products amongst the quantities collected? *
You will need that information in order to complete your collector claim forms and to complete your UOMA NB annual statement.

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 drum 240L wheeled bins 360L wheeled bins
Do you have a scale to weigh the USED AEROSOL CONTAINERS (lubricants and brake cleaners only) containers you've collected? *

Yes No
When was your last weighing scale calibration? *
Indicate the date (YYYY-MM-DD)
Products applicable to UOMA NB's program originating from other provinces are NON-UOMA NB products.
Are you collecting USED AEROSOL CONTAINERS applicable to UOMA NB's program in other provinces than New-Brunswick? *

Yes No
What control will you implement in order to determine what qualifies as UOMA NB and NON-UOMA NB products amongst the quantities collected? *
You will need that information in order to complete your collector claim forms and to complete your UOMA NB annual statement.

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

Cheque Electronic funds transfer (EFT)
Would you like to receive payments by cheque or electronic funds transfer (EFT)? *

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

Attach your file

Cancel of
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 - Mois Jour
Date
Should be Empty:

UOMA NB - Collector registration application form