NCTH06421011_Application_9242021

A household hazardous vaste I.D. number shalI be required to ship collected materialsoff-site for treatment and/or processing.
Please ched<the appropriate box and fill in the blank
Facility/Event Host Details I�
Facility/EventHost* Consolidated Diesel Company
Contact Person* Natalie Schoonover
Mailing Address Street* 9337 N US HWY 301 PO Box 670
City* Whitakers State* NC
Postal/ZpCode* 27891 County* Nash
Phone* 3617289401 Email* [e-mail]
Operator/Contractor
On -site Contractor* Clean Harbors Enviornmental Services
Contact Person* Todd Sheaffer
Wiling Address Street* 208 Watlington Industrial Drive
City* Reidville State* NC
Postal/ZZp Code* 27320
Phone* 540-529-5307 Email [e-mail]
Transporter I�
Company Name* Clean Harbors Enviornmental Services
ID Number MAD039322250
Contact Person* Todd Sheaffer
Meiling Address Street* 208 Watlington Industrial Drive
City* Reidville State* NC
Postal/Zp Code* 27320
Phone* 540-529-5307 Email [e-mail]
Dispose r/Re cycler
Company Name* Clean Harbors Environmental Services
ID Number MAD039322250
Contact Person* Todd Sheaffer
Meiling Address Street* 208 Watlington Industrial Drive
City* Reidsville State* NC
Postal/ZZp Code* 27320
Phone* 540-529-5307 Email [e-mail]

Collection Details
Physical Location of 1100 N. Wesleyan Blvd, Rocky Mount, NC 27804 - Golden East Crossing Mall
Event/Facility*
Date of Temporary Event 11/13/2021
(if applicable) *
Event Start Time* 09:00:00 AM
Event End Time* 01:00:00 AM
Materials to be cleaners, herbicides, aerosols, paint, varnishes, batteries, solvents, motor oil
Collected*
Materials to be Recoed* paint, batteries,motor oil, paper, cardboard
Additional Comments Clean Harbors will be the generator of the waste
Certification of Operator/Contractor
I certify that the information supplied is accurate and correct to the best of my knowledge and belief, and that
this facility will only accept household hazardous waste. I am authorized to make this request on behalf of the
operator at the location given.
Signature*
Approved:9/24/21
No. 06421011
Date 09/24/2021
Email* [e-mail]