EOEEA-DEP – Department of Environmental Protection

Responsible Party Contact Information

Name(Required)

First Last

Title(Required)

Organization(Required)

Address(Required)

Street Address City State ZIP Code

Email Address(Required)

Phone(Required)

Mattress Description and Condition

Date or range of dates that the mattress(es) were collected(Required)

Through this date

Condition that prevents recycling(Required)

What prevented recycling of the mattress(es)? Check all that apply and indicate the number of mattress(es) with that condition. Note: 98% of mattresses are recyclable; stains, rips, and wear and tear do NOT render a mattress un-recyclable.

Moldy or excessively wet

Obvious evidence of bedbug infestation

Other condition that prevents recycling

Number of mattress(es) that were moldy or excessively wet?(Required)

Please enter a number greater than or equal to 1.

Number of mattress(es) with obvious evidence of bedbug infestation(Required)

Please enter a number greater than or equal to 1.

Number of mattress(es) with other conditions that prevents recycling(Required)

Please enter a number greater than or equal to 1.

Describe the condition(Required)

Number of mattresses(Required)

Name of mattress recycling facility that rejected the mattress(es)(Required)

Name of person that inspected the mattress(es)(Required)

Must be recycling company staff or staff at your organization familiar with mattress recycling acceptance requirements

First Last

Title of person that inspected the mattress(es)(Required)

Must be recycling company staff or staff at your organization familiar with mattress recycling acceptance requirements

Where did the mattress(es) come from? Check all that apply(Required)

Curbside residential route

Illegal dumping site (must provide location / nearest address)

Municipal transfer station

Mattress recycling facility

My organization’s facility

Describe the location and nearest address for the illegal dumping site(Required)

Questions for Municipal Officials

Do you have a mattress recycling program for residents?(Required)

Yes

How do you inform residents about how to manage an unwanted mattress? (e.g. information on municipal recycling webpage; trash hauler tags mattress and leaves at the curb)(Required)

Solid Waste Disposal Information

Name of the solid waste hauler collecting the mattress(es)(Required)

Name of the solid waste facility mattress(es) will be sent for disposal(Required)

Certification Statement

Under the pains and penalties of perjury, I hereby certify that I have inspected the mattresses listed on this certification and deemed them to be unrecyclable based on the reasons listed above. I have personally examined and am familiar with the information submitted herein and to the best of my knowledge, the information submitted to MassDEP in this Certification, is true, accurate, and complete.

Certification(Required)

Yes, I certify

Date(Required)

Name(Required)

First Last