Department of Resources Recycling and Recovery
Certification and Registration Branch
Application Instructions for
Supplemental Pilot Project Jurisdictions
General Instructions for Supplemental Jurisdiction Applicants:
• It is preferred that pilot project applications be typed using the provided electronic, fillable PDF form. • 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 required information with your application, including attachments. • If you have questions, please e-mail CalRecycle at: [email protected]
Section 1 – Name of Supplemental Applicant Jurisdiction: This is the name of the jurisdiction that is applying to join an existing pilot project.
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 public website.
Taxpayer ID: THIS FIELD CANNOT BE LEFT BLANK OR YOUR APPLICATION WILL NOT BE ACCEPTED.
This is also known as the Employee Identification Number of the Authorizing Department or Office.
Supplemental
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 U.S. mail, e-mails, and phone calls related to the pilot program. 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 – Provide the name of the existing pilot project you propose to join. (Jurisdiction(s)) Question 2 – Check all that apply.
Note: Contact CalRecycle at [email protected] to obtain convenience zone (CZ) information for your jurisdiction.
Question 3 – Indicate the planned beginning and ending dates of your pilot project.
Question 4 – Include in your application packet a detailed pilot project area map. This map shall show the proposed locations of pilot project recycler(s) and the proposed boundaries of the pilot project area. It shall include convenience zones and other information about the jurisdiction and/or pilot project recycler(s).
Note: Contact CalRecycle at [email protected] to request a convenience zone (CZ) map of your jurisdiction with current convenience zones, operational recycling centers, rural boundaries, city or county boundaries, etc.
Question 5 – Read the question, and answer for your jurisdiction.
Question 6 – 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 beverage container recycling within your jurisdiction.
This must also include a detailed description of how pilot project recycler(s) will operate within your jurisdiction. You may 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 Employer ID Number (EIN): This is the taxpayer I.D. / Federal Employer Identification Number (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(s) of redemption method(s) 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 form, please print out and sign the form. Neither copies, scans, faxes, or e-mails of the form, 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
St
ate of California
Department of Resources Recycling and Recovery
CalRecycle 917SUP (New 8/2022)
State of California
Gavin Newsom, Governor
Pilot Project Application
Supplemental Jurisdiction Application
• Write N/A for any items that are not applicable
SECTION 1 – SUPPLEMENTAL JURISDICTION INFORMATION
Name of Supplemental Applicant Jurisdiction
Authorizing Department or Office
Local Government Agency Type (For multi-party jurisdictions: Complete and attach a separate Section 1, 2 and 5 for each jurisdiction) ❏City ❏ County ❏ Tribe ❏ Combination of Jurisdictions (“Multi-party” - Cities, Counties, and/or Tribal Governments) Business Address (no PO Boxes) Suite/Office City County State Zip Mailing Address (indicate if same as business) Suite/Office City County State Zip Area Code Business Phone
( )
E-
mail Website
Taxpayer ID Required for ALL applications.
SECTION 2 – CONTACT INFORMATION
First Name Middle Name Last Name Suffix
Title Area Code Direct Phone E-mail
Attach a business card. (Optional)
(Cal
Recycle 917SUP – New 8/2022)
DOR USE ONLY
Reg ID _________________
Case # ________________
Pilot # ________________
( )
2 SECTION 3 – PILOT PROJECT DESCRIPTION
1. What pilot project do you propose to join? __________________________________________________________
2. The proposed addition to the existing pilot project will serve (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
3. What are the planned dates of operation for this proposed pilot project? Beginning:__________________________________ Ending:__________________________________
4. Provide an official map of the proposed pilot project area. Include the boundaries of the proposed pilot project area and the proposed location(s) of pilot project recycler redemption locations.
Note: Contact CalRecycle at [email protected] to request an official map of your area.
5. Will your jurisdiction maintain pilot project information and data, and upon request by CalRecycle, be able to provide information related to: 1) Costs to the jurisdiction to operate or monitor a pilot project, and 2) Any complaints received about the pilot project?
❑ Yes
❑ No
6. Describe how this addition to an existing pilot project will meet the requirements of Section 14571.9 of the California Beverage Container Recycling and Litter Reduction Act. Include a description of how the addition of the supplemental applicant will affect compliance with the requirements of section 14571.9 of the Act. Include a description of how the addition of the supplemental applicant and revised pilot project area will affect the previously approved pilot project.
Include an analysis of the potential impacts on beverage container recycling within your jurisdiction and on the existing pilot project jurisdiction(s) as a result of the addition of the supplemental applicant. This should also include a detailed description of how the pilot project recycler(s) will operate the proposed pilot project within your jurisdiction. (Attach additional sheets as necessary.)
______________________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
3 SECTION 4 – PROPOSED PILOT PROJECT RECYCLERS
Attach additional sheets as necessary.
Organization Name Taxpayer / Federal ID - EIN
Organization Contact Person Name (First, Last) Area Code 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 - EIN
Organization Contact Person Name (First, Last) Area Code 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 - EIN
Organization Contact Person Name (First, Last) Area Code 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 - EIN
Organization Contact Person Name (First, Last) Area Code 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 - DECLARATIONS AND SIGNATURES
Who must sign the affidavit: The authorizing individual of the supplemental jurisdiction must sign. a) I
agree to administer the pilot program in compliance with the California Beverage Container Recycling and Li
tter 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 applicati on and s
upporting documents is true and correct and that I am authorized to sign this application.
Executed at: City County State Date
Signature (Must be an original, “wet-ink”, signature) First Name Middle Name Last Name Suffix
Title
Area Code Direct Phone E-mail
INTERNAL CALRECYCLE USE ONLY
Indicate the condition(s) met by this supplemental 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
Supplemental Jurisdiction Application
Before Mailing Your Application, Did You:
❑ Include a Taxpayer / Federal Employer ID Number (EIN)? o All applicants MUST have a Taxpayer / Employer ID in Section 1. ❑ Provide an Original “Wet-Ink” Signature?
o Section 5; see Instructions for requirements.
❑ Provide an Original Pilot Project Application Form?
o If using an electronic, fillable PDF form, when complete, print out the form, have it signed, and mail the original paper application to CalRecycle at the address provided on the form.
Note: Copied, scanned, faxed, or e-mailed application forms will not be accepted.
Do Not Forget to Include:
❑ A written authorization from each constituent entity in the existing jurisdiction, stating that it consents to the addition of the supplemental applicant to the jurisdiction and the resulting change to the pilot project. The written authorization shall be on the consenting jurisdiction’s letterhead and be signed by an individual with the authority to bind the constituent entity. ❑ An official, CalRecycle-provided, map of the proposed pilot project area. ❑ The list of proposed pilot project recyclers.
Tribal Government Applications:
❑ Any tribe seeking approval of a pilot project application, either as a single-party jurisdiction, or as a part of a multi-party jurisdiction, shall provide written authorization for the Division to:
o Enter tribal lands to verify the content of the pilot project application, and; o Enter tribal lands to verify compliance with the Act and pilot program regulations by conducting audits and unannounced inspections of any location where beverage containers are redeemed, weighed, or inspected.