NOTIFICATION FORM ON OWNERSHIP TRANSFER OF TREATED WOOD THE

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NOTIFICATION FORM ON OWNERSHIP TRANSFER OF TREATED WOOD


The prospective buyer identified below has expressed interest in obtaining treated wood from MnDOT for reuse/recycling. Treated wood can include, but is not limited to: copper chromium arsenic (CCA), ammoniacal copper quat (ACQ), copper azole, ammoniacal copper citrate, creosote, and pentachlorophenol (PCP or penta). By signing this document, the buyer certifies that he or she is familiar with proper handling and disposal of this material. The buyer must complete this form to MnDOT’s satisfaction prior to removal of any treated wood. Any change in the method or location of re-use of the materials would require re-submittal and approval.


Source of treated wood: _________________


MnDOT Contract: _____


Buyer: _____ (name, company, mailing address, telephone number)


_____



OWNERSHIP TRANSFER

Description

Quantity

Date Transferred

Comments

















































Buyer assumes all risk and agrees to hold harmless, defend, and indemnify MnDOT for any claim that may be brought against it by any individual, entity, or governmental agency pursuant to any local, state, or federal law or regulation or pursuant to decisional law that is based upon a release or threatened release of a hazardous substance or a pollutant or contaminant occurring on or in the Property.  In addition to requests for monetary compensation, the term “claim” as used herein includes, but is not limited to, demands to MnDOT for clean up or remediation costs, fines, and costs and expenses, including attorneys’ fees.


I certify that the following information is correct:

(Print name of authorized buyer)


The above treated wood will be reused in the following manner:


_____


_____



I also certify that is familiar with Local, State and Federal

(Buyer name)

requirements, including the Minnesota Pollution Control Agency fact sheet “Treated Wood: Use, Disposal and Alternatives for Businesses”, regarding proper handling and disposal of treated wood and the buyer has been notified of this.


______ _____

(Buyer signature) (Date)


Received by MnDOT representative: _____ (Print name)

______ _____

(Signature) (Date)



cc: District File

Office of Environmental Stewardship (Mail stop 620)





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Tags: notification form, notification, treated, transfer, ownership