NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF SOLID AND HAZARDOUS WASTE
Waste Origin and Disposal Form
Return to Enforcement
1. A. Transporter's
DEP Registered Name:

___________________________________________ B. Phone (______)________________
2. Transporter's DEP Numbers:

 

   DEP # Decal # Vehicle Plate Number
Vehicle:      
Trailer:      
Container:      
3. A. Waste Type(s):(Please Circle)
10 13 13C* 23
25 27 27A** 27I***
Other: ___________________
_________________________

* - Construction/Demolition Debris
** - Asbestos   *** - Incinerator Ash

 B. Source Separated Recyclables: (Please Circle)
Paper Corrugated Glass Metal Plastics
Concrete Products Asphalt Wood Yard Material

Other (Please Specify):______________________________
_______________________________________________
4. Waste Origin State (Please Circle):    NJ    PA    NY    DE    MD  Other (Specify):

______________________
5. Municipality(ies) County(ies) % of Total Load
       
     
     
     
     
     
     

6.		 Weighing Facility:

____________________________________________________

 ID#:

________________________
Cubic Yards

_________________
(Completed by Transporter)
 Gross Weight

_________________
(Completed by Weighmaster)

Net Weight

_________________
(Completed by Weighmaster for In-State Disposal only)

Final Disposal Facility: _________________________________________ State: _________ ID #: ____________
(If other than the weighing facility) (If applicable)
7.
Transporter's Certification:  I certify that the information provided on this form is true to the best of my knowledge.

_____________________________________
_____________________________________
____________
Print Driver/Transporter's Name Signature Date
8.
Weighmaster'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.

_____________________________________
____________

Weighmaster's Signature

Date
9.
Final Disposal Facility Operator Certification (In-State Disposal Only):  I certify that this form has been completed by the registered transporter identified above, and that the waste as identified by the transporter is permitted to be disposed of at this facility.

_____________________________________
____________
____________
Operator's Signature Date Time

NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF SOLID AND HAZARDOUS WASTE
Waste Origin and Disposal Form
Return to Enforcement
1. A. Transporter's
DEP Registered Name:

___________________________________________ B. Phone (______)________________
2. Transporter's DEP Numbers:

 

   DEP # Decal # Vehicle Plate Number
Vehicle:      
Trailer:      
Container:      
3. A. Waste Type(s):(Please Circle)
10 13 13C* 23
25 27 27A** 27I***
Other: ___________________
_________________________

* - Construction/Demolition Debris
** - Asbestos   *** - Incinerator Ash

 B. Source Separated Recyclables: (Please Circle)
Paper Corrugated Glass Metal Plastics
Concrete Products Asphalt Wood Yard Material

Other (Please Specify):______________________________
_______________________________________________
4. Waste Origin State (Please Circle):    NJ    PA    NY    DE    MD  Other (Specify):

______________________
5. Municipality(ies) County(ies) % of Total Load
       
     
     
     
     
     
     

6.		 Weighing Facility:

____________________________________________________

 ID#:

________________________
Cubic Yards

_________________
(Completed by Transporter)
 Gross Weight

_________________
(Completed by Weighmaster)

Net Weight

_________________
(Completed by Weighmaster for In-State Disposal only)

Final Disposal Facility: _________________________________________ State: _________ ID #: ____________
(If other than the weighing facility) (If applicable)
7.
Transporter's Certification:  I certify that the information provided on this form is true to the best of my knowledge.

_____________________________________
_____________________________________
____________
Print Driver/Transporter's Name Signature Date
8.
Weighmaster'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.

_____________________________________
____________

Weighmaster's Signature

Date
9.
Final Disposal Facility Operator Certification (In-State Disposal Only):  I certify that this form has been completed by the registered transporter identified above, and that the waste as identified by the transporter is permitted to be disposed of at this facility.

_____________________________________
____________
____________
Operator's Signature Date Time