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DEPARTMENT USE ONLY NEWYORK | Department of BPPORTUNIEY Environmental DEC ACTIVITY # Conservation DATE VALIDATED DIVISION OF MATERIALS MANAGEMENT EXPIRATION DATE REGISTRATION FORM FOR A HOUSEHOLD HAZARDOUS WASTE (HHW) COLLECTION EVENT Please read instructions (found at the end of this document) before completing this application. Attach all required information to this form and submit to the appropriate Regional Materials Management Engineer (see below). This is not a UPA permit. Operations at HHW collection events are not authorized until a registration is validated by the Department. 1. REQUEST TYPE (Check applicable box) (@) Initial C) Renewal Modification DEC Activity Number (for renewal or modification only) 2. EVENT SPONSOR INFORMATION (identify the entity/municipality sponsoring the collection event(s)) Name Town of Aurora Address 575, Qakwood Ave. city/Town Fast Aurora | 7°°°°14052 ‘mall [email protected] Phone 716-652-7596 = | PECResiong 3. PREFERRED CONTACT INFORMATION (Identify the person who will be managing the event(s) ‘ame Ben Garvey Email [email protected] | °°°"* (716) 604-8401 | Recycling Coordinator Other Tow Cousimember 4. COLLECTION EVENT LOCATIONS & OPERATING DAYS AND HOURS (Add additional pages if necessary) Address City/Town Zip Code NY.UTM — E Coordinate NY UTM-N Coordinate Event Date Operating Hours 1. |141 Girard Ave. East Aurora 14052 -18.6300372 42.7717402 10/24/26) 9Yam-ipm 2. 3. 5. VENDOR OR CONTRACTOR INFORMATION (Identify the vendor hired to handle the HHW) Vendor/Contractor Name GreenSheen Paint | “448% 1470 Rotterdam Industrial Park, Building 14, Bay7 | “YT”? Rotterdam Zip Code 4 9306 ‘mall [email protected] | °" ° 716-796-4070 | Part 364 Permit # «77 Expiration Date 0242027 6. SERVICE AREA (List all municipalities within the service area of the event(s), i.e., counties, cities, towns, villages or planning units ) Erie county and surrounding areas 7. SOLID WASTE HANDLED (Check applicable box) | Household Hazardous Waste [| CESQG (Conditionally Exempt Small Quantity Generators) [v] Other PAINT ONLY COLLECTION EVENT 8. CERTIFICATION (Must be completed by the event sponsor (registration holder). Retain a copy of this form and all applicable attachments. | hereby affirm under penalty of perjury that information provided on this form and attached statements and exhibits was prepared by me or under my supervision and direction and is true to the best of my knowledge and belief, and that | have the authority as (title) of (entity) to sign this registration form pursuant to 6 NYCRR Part 360, Section 360.15. By signing this registration form, | affirm that | have read the applicable regulations and will abide by all conditions of the registration requirements under Parts 360, 361, 362, 363, and 365, as applicable. | am aware that any false statement made herein is punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. Printed/Typed Name Signature Date