For generators: For distributors or suppliersadem.alabama.gov/DeptForms/Form569.pdf · For distributors or suppliers that handle 100 dry tons per year or more of the eligible by -product

Alabama Department of Environmental Management Beneficial Use Facility Registration Application

ADEM Form 569 08/19

Application Type: (check one) [ ] New Application [ ] Modification Application

Facility Type: [ ] Generator [ ] Distributor or Supplier

Section 1: Application Information Facility Name:

Address (mailing):

Contact: Telephone:

Email: County:

Address (physical):

Contact: Telephone:

Email: County:

Section 2: Property Owners(s) (if different from applicant)

Name:

Address:

Name:

Address:

Section 3: Attachments to Registration Application For generators:

For generators that handle 100 dry tons per year or more of eligible by-product material for beneficial use, submit the following with the registration application:

A list of distributors or suppliers that handle the by-product material

A copy of their Operations Plan(s).

For distributors or suppliers: For distributors or suppliers that handle 100 dry tons per year or more of the eligible by-product material for beneficial use, submit the following with the registration application:

Site-specific NRCS Comprehensive Nutrient Management Plan(s) detailing at a minimum the following:a. Application site location(s) and property description;b. Brief description of the operation;c. Crops and soils information;d. Yield goal information;e. Timing and method of applications; and,f. Best management practices.

An Operations Plan for handling and transportation of the by-product material which shall include bestmanagement practices for minimizing the following:

a. Vectors and birds;b. Odors;c. Spills; and,d. The amount of time in transit.

Alabama Department of Environmental Management Beneficial Use Facility Registration Application

ADEM Form 569 08/19

Section 4: Operating Record

Physical Location where Records will be maintained:

Address:

Contact: Telephone:

Section 5: Application Fees

Registration Application Fees Included: $______________ (See ADEM Admin Code 335-1 for applicable fees.)

Section 6: Certification of Compliance I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.

Signature of Responsible Corporate Official of registration applicant:

Signature Title

Print or type name Date

Submittal of Application The application may be submitted in paper form or on a compact disk to:

ADEM Solid Waste Branch

Solid Waste Engineering Section

1400 Coliseum Blvd, Montgomery, AL 36110-2059 PO Box 301463, Montgomery, AL 36130-1463

An electronic version of this application may be submitted to ADEM at: [email protected]. If submitting the application electronically, all attachments to this application must also be submitted in an electronic version. Contact ADEM at 334-274-4201 for additional information about this application form.

FOR ADEM USE ONLY

Reviewed By: ____________________________

Date Reviewed: ___________________________

Fees Received: ____________________________

Date Approved: ___________________________

Registration Number: ______________________

FOR ADEM USE ONLY DATE RECEIVED STAMP