New Jersey Certificate Application Form

Certificate of Public Convenience & Necessity Application Checklist

Name:

1. Application completed and notarized. Questions 8-19 must be answered by both corporations and LLC.

2. Experience per question 30 of application.

3. Copy of N.J.S.A. 13:1E-126 et seq. (A-901) approval. Please note that both NJDEP and the Division of Law A-901 Unit must be notified prior to any changes in ownership, including change of address, owners, officers, directors and key employees.

4. Itemized list of equipment per question 31 of application. Applicant may apply for Certificate of Public Convenience and Necessity before he/she possesses equipment.

5. For a corporation attach copy of FILED Certificate of Incorporation.

5a. If not incorporated under laws of the State of New Jersey furnish copy of authority to do business in New Jersey and copy of corporate charter.

5b. For Limited Liability Company FILED "Certificate of Formation".

5c. If applicable, FILED copy of registration of FICTITIOUS/ALTERNATE name.

5d. For proprietorship registration of trade name.

6. Tariff.

7. Statement of financial condition.

8. Proof of Insurance, see item 4.

9. Keep copy of entire application.

For Solid Waste Facility Certificate (landfills, incinerators, transfer stations) only:

10. Solid Waste Facility Permit (contact Tom Byrne for more information (609) 984-6812).

11. Facility must be included in the county's solid waste management plan.

UNLESS A-901 HAS BEEN APPROVED, AND THE APPLICATION IS ADMINISTRATIVELY COMPLETE, YOUR APPLICATION FOR A CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY WILL BE RETURNED.

NOTE: Do not include a payment with this application! The Department of Treasury will send a bill equivalent to one quarter (1/4) of one percent of a company's estimated gross operating revenue.

Mail entire application to:

NJ Department of Environmental Protection
Compliance and Enforcement
Office of Local Environmental Management
Mail Code 09-01A, P.O. Box 420
Trenton, New Jersey 08625-0420

Any questions please call Suzanne Conway (609) 633-1389, Michael DeTalvo (609) 984-6825 or fax (609)292-3991.

Application for Certificate of Public Convenience and Necessity for Solid Waste Collection and/or Disposal

Pursuant to R.S. Title 48:13A-1 et seq., the undersigned hereby makes application for certificate(s) of public convenience and necessity as indicated below and certified, under oath, to the correctness of the following information:

Mark with "X" Nature of Application and Type of Certificate(s) applied for:

Furnish a detailed description of the proposed operation of the applicant's business plan. (Attach additional sheets as necessary.)

Question 1-7 Must be Answered by All Applicants

1. Applicant (print name, address & zip code) as it appears on Applicant's A-901 approval.

2. Trade name, if any, under which business is to be conducted

3. The address of each office in New Jersey from which the business is to be conducted: (List each office and business telephone number.) (Attach additional sheets if necessary.)

4. If the applicant is a proprietorship, give the name, address and date of birth of the proprietor.

Questions 8 - 19 Must be Answered by Corporations & Limited Liability Companies

4a. If applicant is a partnership, give the names, addresses, dates of birth of all partners. Attach copy of partnership agreement(s).

4b. If applicant is any other type of business association (other than a corporation or limited liability corporation), state nature of such association and names, addresses, dates of birth of all principals. (Attach additional sheets if necessary.)

5. List the names, addresses, dates of birth, and titles of those individuals having actual administrative responsibility. (Attach additional sheets if necessary.)

6. If the business is to be conducted at more than one location in this State, provide the name and address of the individual in charge of each such location. (Attach additional sheets if necessary.)

7. Designate the agent in New Jersey upon whom notice process and orders of the Department of Environmental Protection may be served. Furnish the address, zip code and telephone number of such agent. If applicant is out of state, include agent's acceptance of designation by affidavit.

8. Corporate Name of Applicant or LLC:

9. Address of Principal Office:

11. Furnish a copy of the Certificate of Incorporation or Certificate of Formation as filed with the New Jersey Secretary of State.

11a. If not incorporated under laws of the State of New Jersey, furnish copy of authority to do business in New Jersey. (Attach copy of corporate charter.)

11b. If you are a sole proprietor using a trade name, you must register at the County Clerk's office in the county your business is located.

11c. Provide a copy of "Registration of doing business as name or trade name".

11d. If your business is a corporation, a limited liability company or a limited liability partnership, you must register the business with the New Jersey Division of Commercial Recording. Provide a copy of your "State of New Jersey Business Registration" certificate.

11e. All businesses must register for Tax and Employer purposes with the New Jersey Division of Revenue.

12. Provide name and address of Registered or Authorized Agent in New Jersey (as filed with the New Jersey Secretary of State) upon whom process in any proceeding against applicant or proceedings in any court of this State or in the United States District Court for the District of New Jersey, may be served.

13. Provide address of Registered Office in New Jersey

14. List names, addresses, dates of birth of all officers of applicant corporation and office held by each. (Attach additional sheets if necessary.)

15. List names, addresses, dates of birth of all members of the Board of Directors of the applicant corporation. (Attach additional sheets if necessary.)

16. List names, addresses, dates of birth and percent of stock ownership of all stockholders holding five or more percent of the issued and outstanding stock of the applicant corporation. If any stockholder is another corporation, attach rider giving answers to Questions 8 through 19 with respect to each such corporation. (Attach additional sheets if necessary.)

17. Has any corporation, partnership, association or individual other than the stockholders herein set forth any beneficial interest, directly or indirectly, in the stock held by said stockholders?

18. Has any stockholder of the applicant corporation any beneficial interest, directly or indirectly, in the stock of any other stockholder of the applicant corporation?

19. Does the individual signing this application on behalf of said corporation know, or have any reason whatsoever to believe or suspect that any of the officers or directors of said corporation, or any holder, directly or indirectly, by any device or subterfuge whatsoever of more than five percent in beneficial interest of the capital stock of said corporation would fail to qualify as an individual applicant for a certificate hereby applied for in any respect?

Questions 20 - 24 Inclusive Must be Answered by All Applicants

20. Has any individual, partnership, corporation or association, other than the applicant, any interest directly or indirectly, in the certificate applied for or in the business to be conducted under said certificate?

21. Has the applicant agreed to permit any person to receive, or agreed to pay to any employee or other person all or any portion or percentage of the gross or net profits or income derived from the business to be conducted under the certificate applied for?

22. Has the applicant, any person mentioned in Question 5, any employee, or any other person having a beneficial interest ever been convicted of any crime?

23. Has the applicant or any person mentioned in this application ever had any interest, directly or indirectly, in any application for a Solid Waste Collection and/or Disposal Certificate of Public Convenience and Necessity in New Jersey which was denied?

24. Has the applicant or any person mentioned in this application having a beneficial interest ever had interest in any Solid Waste Collection and/or Disposal Certificate in New Jersey or any other state which was surrendered, suspended, revoked or canceled?

Questions 25 - 29 Must be Answered by Solid Waste Disposal Operators

25. Provide the schedule of rates charged to solid waste collectors for disposal at the disposal site. Furnish four copies of tariff in accordance with N.J.A.C. 14:11-7.

26. Provide in detail, any preference given to any solid waste collectors as to time, place or price.

27. Provide the method of disposal used at the disposal site.

28. If a sanitary landfill is operated, provide the capacity.

29. Are you also engaged in the business of solid waste collection?

Requirements Which Must be Satisfied by All Applicants

30. For those persons listed in questions five and six, indicate specific prior experience and education or training in relation to the collection and/or disposal of solid waste.

31. Itemize all equipment including motor vehicles which will be owned and used by applicant for collection and/or disposal of solid waste.

32. Furnish a copy of Certificate of Insurance coverage on all equipment (if applicant has vehicle).

32a. Motor carriers operating commercial motor vehicles in interstate transportation must have at least the minimum amount of insurance required by law.

32b. If applicable provide USDOT Number

33. Applicant must attach a Statement of Financial Condition to include balance sheets and income statement for the end of the most recent one-year period of operations of applicant's business or pro forma statements (12 month basis) for new operations.

34. Applicant must attach a copy of their A-901 Approval Letter as issued by the New Jersey Department of Environmental Protection.

35. If the applicant is engaged in business and presently charging rates, attach a copy of a tariff required by N.J.A.C. 7:26H-4. If the rates charged are embodied in a contract, attach a copy of each such contract.

36. If applicant is new business, attach a copy of a tariff required by N.J.A.C. 7:26H-4 showing rates proposed to be charged.

37. Applicant must attach a description of his/her experience, training, or education in the solid waste collection and/or solid waste disposal industry together with all supporting data.

NOTE: In answering 25 or 36, the schedule of rates must include all factors and variables which enter into the determination of rates to be charged including density of areas served, type of service rendered, frequency of collection, etc. In this regard the schedule is to include what service is rendered for the amount charged. This must be done for each rate.

Verification

The undersigned files this application as

and states that, in such capacity, he is qualified and authorized to file and verify such documents; that he has carefully examined all the statements and matters contained in the application; and that all such statements made and matters set forth are true and correct to the best of his knowledge, information, and belief.

State of )

County of )

Statement of Financial Condition

Applicant must attach a statement of financial condition to include balance sheet and income statements or pro forma statements (12 month basis for new operations).

Company:

Estimated Gross Operating Revenue derived from NJ Solid Waste for one year:

Cash

Account Receivable

Equipment

Other Assets

Total Assets

Liabilities

Total Liabilities

Equity

Assets less Liabilities = Balance

Solid Waste Collection Tariff

Company:

Company President/Owner:

Contact Person:

Telephone Cell phone

Fax:

Registered Agent:

Territory Served

Hours of operation:

The collection will not pick-up waste on the following holidays:

Billing and payment procedures:

List type of service, capacity of truck or container, price and whether dumping fee is included in price