Department of Resources Recycling and Recovery
Certification and Registration Branch
Application Instructions for
Pilot Project Jurisdictions
General Instructions for Jurisdiction Applicants:
Writing must be legible. (Note: You can visit our website and download a fillable PDF.) Read the following instructions prior to completing your application. If a field does not apply to you, do not leave it blank. Instead, write “N/A” for not applicable. Review your application for completeness before submission. Incomplete applications delay the process. Make sure to submit all the required information, including attachments. If you have questions, please call Michael Vanderburg at (916) 327-2769.
Section 1 – Name of Applicant Jurisdiction: This is the name of the jurisdiction that is applying.
Note: If a combination of agencies are applying, fill out and attach a separate Section 1 for each agency.
Authorizing Department or Office: This is the name of the department or office that is applying and has the authority to apply on behalf of the jurisdiction.
Local Government Agency Type: Check the type of government agency that is applying.
Business Address: This is the address where you will store your business records. Include the suite/office number, if applicable. This cannot be a PO Box.
Mailing Address: This is the address where CalRecycle will send important notices. Include the suite/office number, if applicable. This address may be a PO Box. If it is the same as the business address, write “same”.
Business Phone: This phone number should be the general phone number for the jurisdiction. This may be a main front desk number.
E-mail: This is the general e-mail address to reach the jurisdiction. It should be an e-mail address that is checked regularly, as CalRecycle may send important updates about our program to this address on file.
Website: The jurisdiction’s website(s).
Taxpayer ID: THIS FIELD CANNOT BE LEFT BLANK OR YOUR APPLICATION WILL NOT BE ACCEPTED.
This is the Employee Identification Number of the Authorizing Department or Office.
Jurisdiction
Information
Section 2 – Name: The first name, middle name, last name, and suffix (Jr., Sr., III, etc.) of the person who will be the primary contact for your jurisdiction. This person will receive the mail, e-mails, and phone calls.
This person may or may not be the person authorized to sign the application.
Title: This is the contact person’s job title, such as, city manager.
Direct Phone: This is the best phone number for the contact person during normal business hours.
Include the area code.
E-mail: This is the e-mail address for the contact person. Please use an e-mail address that is checked regularly, as CalRecycle may send important updates about our program to this address on file.
Attach a Business Card (Optional): You may attach a business card.
Contact
Information
Section 3 – Question 1 – Check all that apply. Contact CalRecycle at (916) 327-2769 to obtain unserved convenience zone information for your area.
Question 2 – Indicate the planned beginning and ending dates of your pilot project.
Question 3 – Include in your packet a detailed map. This map should outline the proposed locations of pilot project recyclers and the boundaries of the jurisdiction. It may include convenience zones, proposed routes of pilot project recyclers, and other information about the jurisdiction and/or pilot project recyclers.
Note: Make sure to contact CalRecycle to obtain a map of your jurisdiction with current convenience zones, operational recycling centers, rural boundaries, and city or county boundaries.
Question 4 – Include a description of how your pilot project will meet the requirements of Section 14571.9 of the California Beverage Container Recycling and Litter Reduction Act. In this description, include an analysis of the potential impacts on recycling within your jurisdiction. This may also include a detailed description of how pilot project recyclers will operate within your jurisdiction. You may write on the form and/or attach additional pages as necessary.
Pilot Project
Description
Section 4 – Organization Name: This is the organization name of a proposed pilot project recycler operating within your jurisdiction as a part of your pilot project.
Taxpayer/Federal ID: This is the taxpayer/federal ID (EIN) of the proposed pilot project recycler.
Organization Contact Person Name: This is the full name of the contact person for the proposed pilot project recycler.
Contact Phone: This is the best number to reach the contact person for the proposed pilot project recycler. Include the area code.
E-mail: This is the e-mail address to reach the contact person for the proposed pilot project recycler.
Business Address: This is the address where the proposed pilot project recycler will store their business records. Include the Suite/Office number, if applicable. This cannot be a PO Box.
Methods of Redemption: This is the type of redemption method the proposed pilot project recycler will be using. If other, include a brief description that explains how they will redeem empty beverage containers.
Note: There is space in Section 4 to include information for up to four proposed pilot project recyclers. Attach additional pages as necessary.
Proposed Pilot
Project
Recyclers
Section 5 – Who Must Sign the Affidavit: Only the authorizing individual of the jurisdiction (a person legally able to bind the jurisdiction) may sign the affidavit.
Executed at: The city, county, state, and date where this application was signed.
Signature: Sign the application, preferably in blue ink. This must be an original, “wet-ink” signature. If using an electronic, fillable PDF to complete the form, please print and sign. Copies, scans, faxes, nor electronic signatures will be accepted.
Name: The first name, middle name, last name, and suffix (Jr., Sr., III, etc.) of the person who signed the application.
Title: The title of the person who signed the application, such as, city manager.
Direct Phone: The phone number, including area code, where this person can be reached during normal business hours.
E-mail: An e-mail address for the person who signed the application.
Declarations
and Signatures
1 DIVISION OF RECYCLING/CERTIFICATION UNIT
801 K Street, MS 15-59, Sacramento, CA 95814
(916) 324-8598
www.calrecycle.ca.gov
State of California
CalRecycle xxx (April 2019)
State of California
Gavin Newsom, Governor
Department of Resources Recycling and Recovery(CalRecycle) Pilot Project Application
Jurisdiction Application
Please type or print neatly in ink
Write N/A for any items that are not applicable
SECTION 1 – JURISDICTION INFORMATION
Name of Applicant Jurisdiction
Authorizing Department or Office
Local Government Agency Type
❏City ❏ County ❏ Combination of Cities and/or Counties
(Combined cities and/or counties: Complete and attach a separate section 1 for each city or county applying.) Business Address (no PO Boxes) Suite/Office City County State Zip Mailing Address (indicate if same as business) Suite/Office City County State Zip Business Phone
( )
E-mail Website
Taxpayer ID
Required for ALL applications.
SECTION 2 – CONTACT INFORMATION
First Name Middle Name Last Name Suffix
Title Direct Phone
( )
E-mail
Attach a business card. (Optional)
(DOR FORM NUMBER)
DOR USE ONLY
Reg ID _________________
Case # ________________
Pilot # ________________
1 DIVISION OF RECYCLING/CERTIFICATION UNIT
801 K Street, MS 15-59, Sacramento, CA 95814
(916) 324-8598
www.calrecycle.ca.gov
State of California
CalRecycle xxx (New 4/2019)
State of California
Gavin Newsom, Governor
Department of Resources Recycling and Recovery
Pilot Project Application
Jurisdiction Application
Please type or print neatly in ink
Write N/A for any items that are not applicable
SECTION 1 – JURISDICTION INFORMATION
Name of Applicant Jurisdiction
Authorizing Department or Office
Local Government Agency Type
❏City ❏ County ❏ Combination of Cities and/or Counties
(Combined cities and/or counties: Complete and attach a separate section 1 for each city or county applying.) Business Address (no PO Boxes) Suite/Office City County State Zip Mailing Address (indicate if same as business) Suite/Office City County State Zip Business Phone
( )
E-mail Website
Taxpayer ID
Required for ALL applications.
SECTION 2 – CONTACT INFORMATION
First Name Middle Name Last Name Suffix
Title Direct Phone
( )
E-mail
Attach a business card. (Optional)
(CalRecycle xxx)
DOR USE ONLY
Reg ID _________________
Case # ________________
Pilot # ________________
2 SECTION 3 – PILOT PROJECT DESCRIPTION
1. The pilot project serves (check all that apply):
❑ At least three unserved convenience zones
❑ One or more convenience zones impacting a total of at least 30 dealers in unserved convenience zones ❑ A rural region
2. What are the planned dates of operation for this pilot project? Beginning:__________________________________ Ending:__________________________________
3. Provide a detailed map of the pilot project area, include proposed locations of pilot project recyclers.
4. Describe how this pilot project will meet the requirements of Section 14571.9 of the Act. Include an analysis of the potential impacts on recycling in the jurisdiction. (Attach additional sheets as necessary.) ______________________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 2 SECTION 3 – PILOT PROJECT DESCRIPTION
1. The pilot project serves (check all that apply):
❑ At least three unserved convenience zones
❑ One or more convenience zones impacting a total of at least 30 dealers in unserved convenience zones ❑ A rural region
2. What are the planned dates of operation for this pilot project? Beginning:__________________________________ Ending:__________________________________
3. Provide a detailed map of the pilot project area. Include proposed locations of pilot project recyclers.
4. Describe how this pilot project will meet the requirements of Section 14571.9 of the California Beverage Container Recycling and Litter Reduction Act. Include an analysis of the potential impacts on recycling in the jurisdiction. (Attach additional sheets as necessary.)
______________________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 3 SECTION 4 – PROPOSED PILOT PROJECT RECYCLERS
Attach additional sheets as necessary.
Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ 3 SECTION 4 – PROPOSED PILOT PROJECT RECYCLERS
Attach additional sheets as necessary.
Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ Organization Name Taxpayer/Federal ID
Organization Contact Person Name (First, Last) Contact Phone ( )
E-mail
Business Address (no PO Boxes) Suite City County State Zip Method(s) of
Redemption:
❏ Mobile
Service
❏ Stationary
Location
❏ Other (brief description): ___________________________________________________ _________________________________________________________________________ 4 SECTION 5 - DECLARATION AND SIGNATURES
Who must sign affidavit: The authorizing individual of the jurisdiction must sign. a) I agree to administer the pilot program in compliance with the California Beverage Container Recycling and Litter Reduction Act, including all relevant regulations contained in Chapter 5 of Division 2 of Title 14 of the California Code of Regulations.
b) I declare under penalty of perjury under the laws of the State of California that all information on this application and supporting documents is true and correct and that I am authorized to sign this application.
Executed at: City County State Date
Signature
First Name Middle Name Last Name Suffix
Title
Direct Phone
( )
E-mail
INTERNAL USE ONLY
Indication the condition(s) met by this jurisdiction:
❑ This jurisdiction meets the requisite number of unserved zones. ❑ 75% of convenience zones in this jurisdiction are unserved. ❑ This jurisdiction is located in a rural region.
4 SECTION 5 - DECLARATION AND SIGNATURES
Who must sign affidavit: The authorizing individual of the jurisdiction must sign. a) I agree to administer the pilot program in compliance with the California Beverage Container Recycling and Litter Reduction Act, including all relevant regulations contained in Chapter 5 of Division 2 of Title 14 of the California Code of Regulations.
b) I declare under penalty of perjury under the laws of the State of California that all information on this application and supporting documents is true and correct and that I am authorized to sign this application.
Executed at: City County State Date
Signature
First Name Middle Name Last Name Suffix
Title
Direct Phone
( )
E-mail
INTERNAL USE ONLY
Indicate the condition(s) met by this jurisdiction:
❑ This jurisdiction meets the requisite number of unserved zones. ❑ 75% of convenience zones in this jurisdiction are unserved. ❑ This jurisdiction is located in a rural region.
5 Application Checklist
Jurisdiction Application
Before mailing your application, did you:
❑ Include an Employer ID?
o All applicants MUST have an Employer ID in Section 1. ❑ Provide an original signature?
o Section 5; see Instructions for requirements.
Do not forget to include:
❑ A complete Section 1 for each city or county in your jurisdiction. ❑ Additional Section 4 pages, if necessary.
❑ A map of the pilot project area.
❑ The list of proposed Pilot Project Recyclers.
5 Application Checklist
Jurisdiction Application
Before Mailing Your Application, Did You:
❑ Include an Employer ID?
o All applicants MUST have an Employer ID in Section 1. ❑ Provide an Original Signature?
o Section 5; see Instructions for requirements.
Do not forget to include:
❑ A Complete Section 1 for Each City or County in Your Jurisdiction. ❑ Additional Section 4 pages, If Necessary.
❑ A Map of the Pilot Project Area.
❑ The List of Proposed Pilot Project Recyclers.