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Form 5413

INDIANA E-CYCLE
RECYCLER REGISTRATION
DUE NOVEMBER 1
State Form 54139 (R5 / 12-14)
Indiana Department of Environmental Management
This registration is an annual requirement of the Indiana Electronic Waste (E-Waste) Law (IC 13-20.5-1-5) for recycler participation in Indiana E-Cycle. A
recycler in the Indiana E-Cycle is defined as an individual or entity (public or private) that accepts covered electronic devices (CEDs) from Indiana covered
entities (households, small businesses, and public schools) and collectors for the purpose of recycling. Recyclers do not need to be physically located in
Indiana in order to participate in Indiana E-Cycle; however, any CEDs collected as part of a manufacturer’s recycling plan must be collected from Indiana
covered entities by a registered collector and recycled by a registered recycler.
If you are both collecting and recycling e-waste, you must also submit a completed Indiana E-Cycle Collector Registration (State Form 54137) if you wish
to register as a collector with Indiana E-Cycle. Your facility will need to be registered as a collection site if you regularly accept e-waste directly from
Indiana covered entities or if you hold special collection events.
Recycler program years are from January 1 – December 31. This registration form is due November 1 for registration as a recycler for the following
program year.
Please submit this registrationto IDEM’s Office of Pollution Prevention and Technical Assistance via e-mail or mail, utilizing the addresses listed above. If
you have any questions, please call (800) 988-7901.
FOR IDEM USE ONLY
THIS LINE FOR IDEM USE ONLY
Program Year _______ Date Received _____/_____/_______ Confirmation Letter Sent _____/_____/_______ E-mail USPS
SECTION A: E-WASTE RECYCLER INFORMATION
Please complete this section for the recycler’s primary facility you are registering with Indiana E-Cycle.
If you would like to register additional recycling facilities, please proceed to the third page of this registration form after completing all sections on the first
and second pages. For each additional recycling facility, please complete the third page in its entirety and attach to this registration.
Name of Recycler
Street address (number and street)
City/State/Zip Code
Indiana county (if applicable)
Telephone number with area code
Website
Social network page
Is this location a recycling site?
Yes No
Recycler is also registered as a (check all that apply):
Collector Manufacturer
SECTION B: CONTACT INFORMATION
Please indicate the person responsible for ensuring compliance with the Indiana E-Waste Law (IC 13-20.5). Space is provided to list a second contact
person. If you would like an additional person copied on communications from Indiana E-Cycle, please provide their contact information below.
Name of primary contact
Job title
E-mail address
Telephone number with area code (office)
Telephone number with area code (cell)
Mailing address: Street address (if different from Section A)
Mailing address: City/State/ZIP Code (if different from Section A)
Name of additional contact
Job title
E-mail address
Telephone number with area code (office)
Telephone number with area code (cell)
Mailing address: Street address (if different from Section A)
Mailing address: City/State/ZIP Code (if different from Section A)
This area intentionally left blank- form continues below/on back of page.
Indiana Department of Environmental Management
Office of Pollution Prevention & Technical Assistance
100 North Senate Avenue
MC 13-36, IGCN 1225
Indianapolis, Indiana 46204-2222
Telephone (800) 988-7901
//www.in.gov/idem/recycle/2373.htm
Indiana E-Cycle e-mail: E-Cycle@idem.IN.gov
Reset Form
SECTION C1: RECYCLING FACILITIES AND CERTIFICATIONS
If you wish to register more than one facility, please complete as many copies as necessary of the third page of this registration and attach to your
completed registration. If the address listed in Section A is a recycling facility, please complete this section for that location.
Name of recycling facility
Telephone number of facility with area code
Street address of facility (if different from Section A)
City/State/ZIP Code of facility (if different from Section A)
Indiana county (if applicable)
Please check all the certifications that this facility has obtained. If you are registering multiple facilities, please specify certifications for each additional
facility on the additional pages you are attaching.
Only check the box if you have completed the certification by the date the form is submitted. If you are
in the process of completing a certification, please note that under “Other/Pending”.
e-Stewards
e-Stewards Pledge
R2
ISO 14001
ISO 9001
Other/Pending (please specify):
SECTION C2: CERTIFICATION OF COMPLIANCE WITH INDIANA’S E-WASTE MANAGEMENT RULES
Recyclers must document compliance with Indiana’s E-Waste Management Rules (329 IAC 16) for each registered recycling facility. The E-Waste
Management Rules apply to any entity in Indiana that collects, brokers, stores, recycles, resells, dismantles, or demanufactures e-waste. These rules
outline the storage, operating, training, disposal, and closure requirements for operating as an e-waste storage and processing facility in Indiana. An entity
that does not meet any of the exemptions under 329 IAC 16-3-1 must register as an e-waste storage and processing facility with IDEM. Inspections may
be conducted by IDEM to verify exemptions claimed below.
Compliance with the rules is satisfied by one of the following:
Recycling facility is a registered Indiana e-waste storage and processing facility.
Recycling facility is exempt from registration requirements under 329 IAC 16.
Recycling facility is not physically located in Indiana.
Check the box that certifies the compliance status with Indiana’s E-Waste Management Rules (329 IAC 16) for the facility listed above in C1. If you are
registering multiple recycling facilities, please indicate the compliance status of each additional facility on the additional pages you are attaching (see the
third page of this registration).
Recycling facility is a registered Indiana e-waste storage and processing facility under 329 IAC 16.
E-waste storage and processing facility registration number:
Registration under 329 IAC 16 for this collection site is pending; a registration form has been submitted to IDEM.
Recycling facility is exempt from registration requirements under 329 IAC 16.
Please indicate which of the following exemptions applies to the facility:
The facility is storing less than twenty- three (23) tons of e-waste on-site at any given time.
The facility is storing e-waste for less than five (5) days at a time.
The facility holds a valid permit under Indiana’s hazardous waste management facility rules (329 IAC 3.1), solid waste land disposal facility
rules (329 IAC 10), or solid waste processing facility rules (329 IAC 11).
Recycling facility is not physically located in Indiana.
SECTION D: SIGNATURE AND CERTIFICATION STATEMENT
By submitting this document, I hereby certify that the recycler listed on this registration form has complied and will continue to comply with the
requirements of the Indiana E-Waste Law (IC 13-20-5).
Name (typed or printed)
Title (typed or printed)
Signature
Date signed (month, day, year)
Please submit the completed and signed Indiana E-Cycle recycler registration byNovember 1 via e-mail: E-Cycle@idem.IN.gov -OR-
mail to:
IDEM – OPPTA
Indiana E-Cycle
100 North Senate Ave.
MC 13-36, IGCN 1225
Indianapolis, IN 46204-2222
SECTION C1: RECYCLING FACILITY AND CERTIFICATIONS (ADDITIONAL SITES)
If you wish to register more than one facility, please complete as many copies as necessary of this page and attach to the completed registration.
Name of additional recycling facility
Telephone number of facility with area code
Street address of facility (number and street)
City/State/ZIP Code of facility
Indiana county (if applicable)
Please check all the certifications that this facility has obtained. If you are registering multiple facilities, please specify certifications for each additional
facility on the additional pages you are attaching. Only check the box if you have completed the certification by the date you submit this form. If you are in
the process of completing a certification, please note that under “Other/Pending”.
e-Stewards
e-Stewards Pledge
R2
ISO 14001
ISO 9001
Other/Pending (please specify):
SECTION C2: CERTIFICATION OF COMPLIANCE WITH INDIANA’S E-WASTE MANAGEMENT RULES
Recyclers must document compliance with Indiana’s E-Waste Management Rules (329 IAC 16) for each registered recycling facility. The E-Waste
Management Rules apply to any entity in Indiana that collects, brokers, stores, recycles, resells, dismantles, or demanufactures e-waste. These rules
outline the storage, operating, training, disposal, and closure requirements for operating as an e-waste storage and processing facility in Indiana. An entity
that does not meet any of the exemptions under 329 IAC 16-3-1 must register as an e-waste storage and processing facility with IDEM. Inspections may
be conducted by IDEM to verify exemptions claimed below.
Compliance with the rules is satisfied by one of the following:
Recycling facility is a registered Indiana e-waste storage and processing facility.
Recycling facility is exempt from registration requirements under 329 IAC 16.
Recycling facility is not physically located in Indiana.
Check the box that certifies the compliance status with Indiana’s E-Waste Management Rules (329 IAC 16).
Recycling facility is a registered Indiana e-waste storage and processing facility under 329 IAC 16.
E-waste storage and processing facility registration number:
Registration under 329 IAC 16 for this collection site is pending; a registration form has been submitted to IDEM.
Recycling facility is exempt from registration requirements under 329 IAC 16.
Please indicate which of the following exemptions applies to the facility:
The facility is storing less than twenty-three (23) tons of e-waste on-site at any given time.
The facility is storing e-waste for less than five (5) days at a time.
The facility holds a valid permit under Indiana’s hazardous waste management facility rules (329 IAC 3.1), solid waste land disposal facility
rules (329 IAC 10), or solid waste processing facility rules (329 IAC 11).
Recycling facility is not physically located in Indiana.
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