Get Rejection Report

WASTE REJECTION REPORT Clear Form NORTH DAKOTA DEPARTMENT OF HEALTH DIVISION OF WASTE MANAGEMENT SFN 60120 8-2012 918 East Divide Avenue 3rd Floor Bismarck ND 58501-1947 Telephone 701-328-5166 Fax 701-328-5200 This form is intended for Transporters of Solid Waste that have a load of waste rejected for containing materials not allowed for disposal at a disposal facility. A signed copy of this form shall be provided to the Department at the above address within 5 days upon rejection of the waste. Date of Waste Rejection Time of Waste Rejection Description and Volume of Rejected Waste Reason for Rejection WASTE TRANSPORTER Company Name Address City Contact Name E-mail Address State ZIP Code Telephone Number North Dakota Waste Hauler Permit Number Required WHVehicle Description License Plate Number Driver Name Driver Telephone Number WASTE GENERATOR FACILITY REJECTING THE WASTE Facility Name WHERE THE WASTE WAS FINALLY DISPOSED Transporter/Driver Signature. A signed copy of this form shall be provided to the Department at the above address within 5 days upon rejection of the waste. Date of Waste Rejection Time of Waste Rejection Description and Volume of Rejected Waste Reason for Rejection WASTE TRANSPORTER Company Name Address City Contact Name E-mail Address State ZIP Code Telephone Number North Dakota Waste Hauler Permit Number Required WHVehicle Description License Plate Number Driver Name Driver Telephone Number WASTE GENERATOR FACILITY REJECTING THE WASTE Facility Name WHERE THE WASTE WAS FINALLY DISPOSED Transporter/Driver Signature.