Instructions for Application for Reduced Tip Fee Programs Please fill
Instructions for Application for Reduced Tip Fee Programs Please fill in all applicable information 1-Check which reduced tip fee program you are applying for 2-Requestor Information Community Improvement Program: Information on the municipality or non-profit organization that is requesting approval for the reduced tip fee pricing for construction and demolition projects Residential Cleanup Program: Information on the municipality that is sponsoring the community or residential cleanup event. The application must be submitted through the applicable county solid waste manager’s office. Other: Information on the company/organization/municipality, etc. that is requesting a reduced rate. 3-Project Information Community Improvement Program: Complete all information pertinent to the specific site from which the waste will be received. Include a detailed explanation to justify that this project meets the criteria for the program. This program is for municipal and non-profit construction and demolition projects only. The reduced tip fee is a set rate indicated at the top of the application. Residential Cleanup Program: For cleanup programs held at transfer stations or specific sites, provide site name and location. For waste that is picked up throughout a community, rather than at a specific site, list the name of the community as the site name and indicate that it is community wide in place of an address. In the description, indicate that it is a municipal sponsored cleanup event. The reduced tip fee is a set rate indicated at the top of the application. Other: Complete all the information pertinent to the specific site from which the waste will be received. Indicate the reduced rate tip fee that you are requesting. Please provide a specific description of the project and a reason for the request for the reduced rate. 4-Hauler Information For all requests, provide the information on the company that will be hauling the material to the Authority’s landfill facility. The hauler must have a current Authority issued permit to use the facility. Include the hauler’s permit number on the application. For waste coming through a county transfer station, the county should be listed as hauler.
5-Contractor Information (If Applicable) Residential Cleanup Program: Not applicable Community Improvement Program and all other requests: Please provide the information on the company that is performing the construction, demolition or excavation work for the project. 6-Billing Information Community Improvement Program: The tip fees must be billed to and paid by the municipality / non-profit that is requesting the reduction. Residential Cleanup Program: For direct hauled waste, tip fees must be billed to and paid by the municipality requesting the reduction. For waste coming through a county transfer station, the tip fees will be billed through the sponsoring county. Other: Please complete all the information for the company /organization/ municipality that will be billed for the tip fees. A credit application must be completed if a company / organization does not have an established account in good standing. 7-Applicant Signature The applicant listed as “Requestor” must sign and date the application. Residential Cleanup Program: The application must also be signed by the sponsoring county representative.
Development Authority of the North Country Solid Waste Management Facility Rodman, NY Application for Reduced Tip Fee Programs Please complete electronically or print legibly
____Community Improvement $31.50 / ton (For municipal construction & demolition projects) ____Residential Clean-Up $36.00 / ton (For municipally sponsored spring & fall clean-up days) ____Other (Indicate requested rate under project information) Requestor Information Applicant Name: __________________________________ Title:__________________________ Municipality / Agency Name:________________________________________________________ Address: _________________________________________________________________ City, State, Zip: _________________________________________________________________ Email address: _____________________________Phone:______________Fax:_____________ Project Information Site Name: ____________________________________________________________________ Site Address:____________________________________________________________________ City, State, Zip, County:___________________________________________________________ Waste Type To Be Disposed:_________________________Amount (Tons)__________________ Project Date / Timeframe: _________________________________________________________ Is property owned by the municipality or non-profit agency?: _____Yes _____No Are municipal / non-profit agency funds paying for the project?: _____Yes _____ No Tip Fee Requested: $__________________ Is waste being transported: _____ Through a county transfer station (billed through county) _____Direct to landfill by municipality _____Direct to landfill by private hauler Please describe the project and/or justify the reason for a reduced tip fee: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Hauler Information Contact Name:________________________________Title:______________________________ Company Name:_________________________________________________________________ Address:_______________________________________________________________________ City, State, Zip, County:___________________________________________________________ Phone:__________________ Fax:___________________SWMF Permit #:__________________ Email Address:__________________________________________________________________
Contractor Information (If Applicable) Contact Name:________________________________Title:______________________________ Company Name:_________________________________________________________________ Address: ______________________________________________________________________ City, State, Zip, County:___________________________________________________________ Phone:_______________ Fax:_______________Email:__________________________________ Billing Information Company Name:_________________________________________________________________ Address: ______________________________________________________________________ City, State, Zip: _________________________________________________________________ SWMF Account #: __________________________ Note: For Community Improvement and Residential Clean-Up Requests, the tip fees must be billed to the Municipality / Non-Profit Agency if direct hauled. Signature of Applicant:_______________________________________Date:_________________ Signature of Sponsoring County:_______________________________Date:_________________ (if applicable) **************************************************************************************************************** Approvals: Authority Use Only Authorized Authority Signature:_________________________________Date:________________ Printed Name:_________________________________Title:______________________________ SWMF Project # (if applicable):____________________Waste Class ID#:____________________ Tip Fee Rate / Ton Approved: _____________________
5-Contractor Information (If Applicable) Residential Cleanup Program: Not applicable Community Improvement Program and all other requests: Please provide the information on the company that is performing the construction, demolition or excavation work for the project. 6-Billing Information Community Improvement Program: The tip fees must be billed to and paid by the municipality / non-profit that is requesting the reduction. Residential Cleanup Program: For direct hauled waste, tip fees must be billed to and paid by the municipality requesting the reduction. For waste coming through a county transfer station, the tip fees will be billed through the sponsoring county. Other: Please complete all the information for the company /organization/ municipality that will be billed for the tip fees. A credit application must be completed if a company / organization does not have an established account in good standing. 7-Applicant Signature The applicant listed as “Requestor” must sign and date the application. Residential Cleanup Program: The application must also be signed by the sponsoring county representative.
Development Authority of the North Country Solid Waste Management Facility Rodman, NY Application for Reduced Tip Fee Programs Please complete electronically or print legibly
____Community Improvement $31.50 / ton (For municipal construction & demolition projects) ____Residential Clean-Up $36.00 / ton (For municipally sponsored spring & fall clean-up days) ____Other (Indicate requested rate under project information) Requestor Information Applicant Name: __________________________________ Title:__________________________ Municipality / Agency Name:________________________________________________________ Address: _________________________________________________________________ City, State, Zip: _________________________________________________________________ Email address: _____________________________Phone:______________Fax:_____________ Project Information Site Name: ____________________________________________________________________ Site Address:____________________________________________________________________ City, State, Zip, County:___________________________________________________________ Waste Type To Be Disposed:_________________________Amount (Tons)__________________ Project Date / Timeframe: _________________________________________________________ Is property owned by the municipality or non-profit agency?: _____Yes _____No Are municipal / non-profit agency funds paying for the project?: _____Yes _____ No Tip Fee Requested: $__________________ Is waste being transported: _____ Through a county transfer station (billed through county) _____Direct to landfill by municipality _____Direct to landfill by private hauler Please describe the project and/or justify the reason for a reduced tip fee: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Hauler Information Contact Name:________________________________Title:______________________________ Company Name:_________________________________________________________________ Address:_______________________________________________________________________ City, State, Zip, County:___________________________________________________________ Phone:__________________ Fax:___________________SWMF Permit #:__________________ Email Address:__________________________________________________________________
Contractor Information (If Applicable) Contact Name:________________________________Title:______________________________ Company Name:_________________________________________________________________ Address: ______________________________________________________________________ City, State, Zip, County:___________________________________________________________ Phone:_______________ Fax:_______________Email:__________________________________ Billing Information Company Name:_________________________________________________________________ Address: ______________________________________________________________________ City, State, Zip: _________________________________________________________________ SWMF Account #: __________________________ Note: For Community Improvement and Residential Clean-Up Requests, the tip fees must be billed to the Municipality / Non-Profit Agency if direct hauled. Signature of Applicant:_______________________________________Date:_________________ Signature of Sponsoring County:_______________________________Date:_________________ (if applicable) **************************************************************************************************************** Approvals: Authority Use Only Authorized Authority Signature:_________________________________Date:________________ Printed Name:_________________________________Title:______________________________ SWMF Project # (if applicable):____________________Waste Class ID#:____________________ Tip Fee Rate / Ton Approved: _____________________
