■ 폐기물관리법 시행규칙 [별지 제5호서식] <개정 2020. 5. 27.>                                                 
     [ ] 수탁처리능력 확인서                                                                                    
   [ ] 폐기물 수탁확인서                                                                                        
  ※ 제3쪽의 작성방법을 읽고 작성하시기 바라며, [  ]에는 해당되는 곳에 √표를 합니다.     (제1쪽)               
────┬─────────────────────────┬─────────────────────────
  (1)   │ ① 상호(명칭)                                    │ ② 사업자등록번호                                
  위탁자├─────────────────────────┼─────────────────────────
        │ ③ 성명(대표자)                                  │ ④ 생년월일                                      
        ├─────────────────────────┴─────────────────────────
        │ ⑤ 주소(사업장)                                                                                      
        │ (전화번호:                         )                                                                 
        ├───────────────────────────────────────────────────
        │⑥ 위탁 폐기물                                                                                        
        ├─────────┬───────┬───────┬─────────┬─────┬─────────
        │폐기물 종류       │성질·상태    │위탁량(톤/년) │폐기물 종류       │성질·상태│위탁량(톤/년)     
        │(분류번호)        │              │              │(분류번호)        │          │                  
        ├─────────┼───────┼───────┼─────────┼─────┼─────────
        │(    -    -    )  │              │              │(    -    -    )  │          │                  
        ├─────────┼───────┼───────┼─────────┼─────┼─────────
        │(    -    -    )  │              │              │(    -    -    )  │          │                  
────┴─────────┴───────┴───────┴─────────┴─────┴─────────
────┬─────────┬───────────────┬─────────┬───────────────
  (2)   │ ⑦ 상호(명칭)    │                              │ ⑧ 사업자등록번호│                              
  수탁자├─────────┼───────────────┼─────────┼───────────────
        │ ⑨ 성명(대표자)  │                              │ ⑩ 생년월일      │                              
        ├─────────┼───────────────┴─────────┴───────────────
        │ ⑪ 주소(사업장)  │                                                                                  
        │                  │                                       (전화번호:                              )  
        ├─────────┼───────────────┬─────────┬───────────────
        │ ⑫ 업종          │                              │ ⑬ 기술능력      │                              
        ├─────────┴───────────────┴─────────┴───────────────
        │⑭ 폐기물처리업 허가 또는 폐기물처리 신고 관련 사항                                                   
        ├─────────┬─────────────────────────┬───────────────
        │허가(신고)번호    │허가(신고)일(최종 변경일)                         │허가(신고수리)기관            
        ├─────────┼─────────────────────────┼───────────────
        │                  │                                                  │                              
────┴─────────┴─────────────────────────┴───────────────
────┬─────────────┬─────────────────────────────────────
  (3)   │⑮ 방치폐기물처리 이행보증│공제조합가입( ), 보증보험가입( )                                          
  수탁  ├─────────────┴─────────────────────────────────────
  처리  │수탁자의 허가 또는 신고 사항                                                                          
  능력  ├───┬─────┬───────┬──────────┬─────────┬────────────
  확인  │      │ 영업대상 │ 폐기물       │ 폐기물 중간처분    │ 폐기물           │ 수집·운반차량         
        │허가  │폐기물    │처분 또는     │또는 재활용 시설    │최종처분시설      │                        
        │또는  │          │재활용 방법   ├──┬───────┼────┬────┼────┬───────
        │신고  │          │              │종류│용량(톤/시간) │용량    │매립기간│규모(톤)│수량(대)      
        │업종  │          │              │    │              │(㎥)    │        │        │              
        ├───┼─────┼───────┼──┼───────┼────┼────┼────┼───────
        │      │          │              │    │              │        │        │        │              
        ├───┴─────┴───────┴──┴───────┴────┴────┴────┴───────
        │ 수탁자(최종처분업자 외의 자)의 처리능력(단위: 톤)                                                    
        ├─────────┬───────┬───────┬──────┬───────┬──────────
        │허용보관량        │현재 폐기물   │1일 평균      │금회 폐기물 │전체 폐기물   │1일 폐기물 처리     
        │                  │보관량        │폐기물 반입량 │수탁(운반)량│보관량        │(운반)량            
        ├─────────┼───────┼───────┼──────┼───────┼──────────
        │                  │              │              │            │              │                    
        ├─────────┴───────┴───────┴──────┴──┬────┴──────────
        │ 수탁자(최종처분업자)의 처분능력(단위: ㎥)                            │ 수탁 가능 여부               
        ├─────────┬───────┬───────┬─────────┤                              
        │매립 허가용량     │1일 평균      │금회 폐기물   │남은 매립용량     │                              
        │                  │폐기물 반입량 │수탁량        │                  │                              
        ├─────────┼───────┼───────┼─────────┼───────────────
        │                  │              │              │                  │                              
────┴─────────┴───────┴───────┴─────────┴───────────────
  210mm×297mm[백상지 80g/㎡(재활용품)]                                                                         
  (제2쪽)                                                                                                                 
━━━┯━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
  (4) │ 수탁폐기물의 종류별 처리방법                                                                                     
  수탁├──────┬──────┬─────────────────┬──────┬──────────────────
  확인│폐기물 종류 │처분 또는   │폐기물 처분시설 또는 재활용시설   │수탁(예정)량│수탁(예정)방법                      
      │(분류번호)  │재활용 방법 ├──┬──────────────┤(톤/년)     │(톤/회, 회/년)                      
      │            │            │종류│처분 또는 재활용 능력(톤/일)│            │                                    
      ├──────┼──────┼──┼──────────────┼──────┼──────────────────
      │            │            │    │                            │            │                                    
      ├──────┼──────┼──┼──────────────┼──────┼──────────────────
      │            │            │    │                            │            │                                    
───┴──────┴──────┴──┴──────────────┴──────┴──────────────────
─────────────────────────────────────────────────────────────
     [ ] 「폐기물관리법」 제17조제1항제3호 및 같은 법 시행규칙 제16조의7제1호에 따라 위와 같이 폐기물                     
  수탁자의 처리능력을 확인합니다.                                                                                         
     [ ] 「폐기물관리법」 제17조제5항제3호 및 같은 법 시행규칙 제18조의2에 따라 위와 같이 폐기물의                        
  수탁(예정)사실을 확인합니다.                                                                                            
                                                년      월      일                                                        
  위탁자(배출자): (업소명)                               (대표자)                         (서명 또는 인)                  
  수탁자(처리자): (업소명)                               (대표자)                         (서명 또는 인)                  
   시·도지사                                          귀하                                                               
   특별자치시장, 특별자치도지사, 시장·군수·구청장                                                                       
   유역(지방)환경청장                                                                                                     
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
───────┬────────────────────────────────────────────────┬────
  수탁자      │* 수탁자가 위탁자에게 폐기물 수탁처리능력 확인서를 제출하는 경우만 해당합니다.                  │수수료  
  첨부서류    │ 1. 폐기물처리업 허가증 또는 폐기물처리 신고 증명서 사본                                        │        
              │ 2. 「폐기물관리법」 제40조제1항에 따른 방치폐기물 처리이행보증을 확인할 수 있는 서류 사본(위   │없음    
              │탁자가 「폐기물관리법 시행규칙」 제17조제1항 각 호에 해당하는 사업장폐기물배출자인 경우로       │        
              │한정합니다)                                                                                     │        
───────┼────────────────────────────────────────────────┤        
  담당 공무원 │* 「폐기물관리법 시행규칙」 제17조제1항 각 호에 해당하는 사업장폐기물배출자가 폐기물 수탁처리능 │        
  확인사항    │력 확인서를 첨부하여 사업장폐기물배출자의 (변경)신고를 하거나 폐기물처리계획의 (변경)확인신청   │        
              │을 하는 경우만 해당합니다.                                                                      │        
              │- 폐기물처리업 허가증 또는 폐기물처리 신고 증명서(행정정보 공동이용으로 해당 서류를 확인할 수   │        
              │없거나 행정정보 공동이용에 동의하지 않는 경우에는 해당 서류의 사본을 첨부하도록 해야 합니다)    │        
───────┴────────────────────────────────────────────────┴────
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
  행정정보 공동이용 동의서                                                                                                
─────────────────────────────────────────────────────────────
   본인은 이 건 업무처리와 관련하여 「전자정부법」 제36조제1항에 따른 행정정보의 공동이용을 통하여 담당 공무원이 위의 담당   
  공무원 확인사항을 확인하는 것에 동의합니다.                                                                             
                        신고인(신청인)                                                  (서명 또는 인)                    
─────────────────────────────────────────────────────────────
  (제3쪽)                                                                                                                                                                   
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
  작성방법                                                                                                                                                                  
  <업소별>                                                                                                                                                                  
  1. 위탁자(배출자)는 ①란부터 ⑥란까지 적은 후 대표자나 폐기물관리책임자가 서명 또는 날인합니다.                                                                           
  2. 수탁자(처리자)는 ⑦란부터 란까지 적고, 폐기물 수집·운반업자는 란, 란, 란을, 폐기물 중간처분업자, 폐기물                                                               
  재활용업자 및 폐기물처리 신고자는 란, 란, 란, 란을, 폐기물 최종처분업자는 란, 란, 란, 란을, 폐기물                                                                        
  종합처분업자는 란부터 란까지 모두 적은 후 대표자가 서명·날인하여 위탁자에게 제출합니다.                                                                                  
  <항목별>                                                                                                                                                                  
  1. 수탁처리능력 확인 시에는 해당 [ ]에 표시를 하고 (1)란부터 (3)란까지를, 폐기물 수탁확인 시에는 해당 [ ]에 표시를 하                                                     
  고 (1)란, (2)란 및 (4)란을 적되, 수탁처리능력 확인과 폐기물 수탁확인을 병행할 경우에는 모든 [ ]에 각각 표시를 하고                                                        
  (1)란부터 (4)란까지를 모두 적습니다.                                                                                                                                      
  2. ⑥란 중 폐기물 종류(분류번호)란에는 「폐기물관리법 시행규칙」 별표 4에 따른 사업장폐기물의 명칭과 분류번호를 적고,                                                     
  성질·상태란에는 아래 참고란의 폐기물처리 방법별 분류에 따라 고체상태이면 "1"로, 액체상태이면 "2"로, 지정폐기물을                                                         
  함유한 용기(철제드럼, 폴리에틸렌용기 등)는 "기타"로 적으며, 위탁량(톤/년)란에는 연간 위탁처리하는 폐기물의 양을 톤                                                        
  단위로 적습니다.                                                                                                                                                          
  3. ⑫란은 한국표준산업분류의 대분류에 따른 업종명을, 란은 한국표준산업분류의 소분류에 따른 업종명을 적습니다.                                                             
  4. ⑮란은 공제조합가입 또는 보증보험가입 중 해당하는 ( )안에 "○" 표시하고, 그 이행보증금액을 적습니다.                                                                   
  5. ?란은 생활폐기물, 사업장생활계폐기물, 사업장배출시설계폐기물, 건설폐기물, 의료폐기물 외의 지정폐기물 또는 의료폐기물로                                                
  구분하여 적되, 폐기물처리업 허가증에 적힌 영업대상폐기물 또는 폐기물처리 신고증명서에 적힌 재활용대상폐기물을 모두 적                                                     
  습니다.                                                                                                                                                                   
  6. ?란은 아래 참고란의 폐기물처리 방법별 분류에 따라 처리분류와 세분류 번호를 모두 적습니다.                                                                             
  7. ?란은 수집·운반업자의 경우에는 허가받은 수집운반차량을, 폐기물처리 신고자를 포함한 중간처분업자·재활용업자·최종처                                                  
  분업자의 경우에는 직접 운반하는 수집운반차량을 모두 적습니다.                                                                                                             
  8. ?란은 보관장소를 승인받은 폐기물 수집·운반업자, 폐기물 중간처분업자, 폐기물 재활용업자, 폐기물처리 신고자가 아래와                                                   
  같은 방법으로 적습니다.                                                                                                                                                   
    가. 허용보관량: 폐기물의 종류별로 허가를 받거나 신고한 허용보관량을 기재                                                                                                
    나. 현재 폐기물 보관량: 확인서 발급일 전일을 기준으로 보관 중인 폐기물량을 기재                                                                                         
    다. 1일 평균 폐기물 반입량: 확인서 발급시점을 기준으로 계약된 전체 폐기물량을 최근 1년 동안의 가동 일수로 나눈 양을 기재                                                
      수탁처리능력 확인서 발급업체의 계약예정물량은 제외하며, 계약기간이 1년을 초과하는 경우에는 1년 동안 계약된 물량만 산입                                                
      가동일수가 1년 미만인 경우에는 연간 예정 가동일수를 적용                                                                                                              
      1일 평균 반입량은 계약물량의 변경에 따라 함께 변경됨                                                                                                                  
    라. 금회 폐기물 수탁(운반)량: 확인서 발급업체와 계약한 폐기물량의 1일 평균반입량을 기재                                                                                 
    마. 전체 폐기물 보관량: (현재의 폐기물 보관량 + 1일 평균 폐기물 반입량 + 금회 폐기물 수탁량 - 1일 폐기물 처리량)에 따라                                                 
  계산된 값을 기재                                                                                                                                                          
      계산결과 (-)값이 되는 경우에도 그 값을 기재                                                                                                                           
    바. 1일 폐기물 처리(운반)량: 해당업체가 허가를 받거나 신고한 1일 폐기물 처리(운반)량을 기재                                                                             
      보관장소를 승인받지 못한 수집·운반업자의 경우에는 금회 폐기물수탁(운반)량 및 폐기물처리(운반)량을 기재                                                               
  9. 란은 폐기물 최종처분업자가 적고, 폐기물 종합처분업자는 란, 란을 모두 적습니다.                                                                                         
  10. 란은 폐기물 수집·운반업자의 경우에는 수집·운반 가능 여부를, 폐기물 중간처분업자, 폐기물 재활용업자, 폐기물 종합처                                                   
  분업자, 폐기물처리 신고자의 경우에는 처분 또는 재활용 가능 여부를 적되, "가능 또는 불가능"으로 적습니다.                                                                  
  11. 란 중 폐기물 종류(분류번호)란에는 「폐기물관리법 시행규칙」 별표 4에 따른 사업장폐기물의 명칭과 분류번호를 적고,                                                      
  처분 또는 재활용 방법란에는 아래 참고란의 폐기물처리 방법별 분류에 따른 분류번호를 적으며, 폐기물 처분시설 또는 재활용                                                    
  시설란에는 그 시설을 구체적으로 적고, 수탁(예정)량란에는 1년 동안 수탁받을 폐기물 예정량을 적으며, 수탁(예정)방법란에                                                     
  는 1회에 수탁받을 폐기물 예정량과 1년 동안 수탁받을 예정횟수를 적습니다.                                                                                                  
  ┌────┬──────────────────────────────────────────────────────────────┐<참고>: 폐기물처리 방법별 분류  
  │처리구분│처리방법                                                                                                                    │                                
  │        ├─────┬────────────────────────────────────────────────────────┤                                
  │        │처리분류  │세분류 번호                                                                                                     │                                
  ├────┼─────┼────────────────────────────────────────────────────────┤                                
  │자가처리│재활용    │원형 재사용[1001], 수리·수선 재사용[1002], 원료 제조[1003], 직접 제품제조[1004], 농업생산활동에 사             │                                
  │        │          │용[1005], 토질개선에 사용[1006], 성토재·복토재 등으로 사용[1007], 직접 에너지회수[1008], 연료·                │                                
  │        │          │고형연료제품 제조[1009], 중간가공폐기물 제조[1010]                                                              │                                
  │        ├─────┼────────────────────────────────────────────────────────┤                                
  │        │중간처분  │일반소각[1101], 고온소각[1102], 열분해[1103], 고온용융[1104], 압축[1105], 파쇄·분쇄[1106], 절단[1107],         │                                
  │        │          │용융[1108], 증발농축[1109], 유수분리[1110], 탈수·건조[1111], 멸균·분쇄[1112], 고형화[1113], 안정화            │                                
  │        │          │[1114], 소멸화[1115], 중화[1116], 기타[1117]                                                                    │                                
  │        ├─────┼────────────────────────────────────────────────────────┤                                
  │        │매립      │관리형 매립시설[1201], 차단형 매립시설[1202], 기타 매립시설[1203]                                               │                                
  │        ├─────┼────────────────────────────────────────────────────────┤                                
  │        │해역배출  │[1300]                                                                                                          │                                
  │        ├─────┼────────────────────────────────────────────────────────┤                                
  │        │수출      │[1500]                                                                                                          │                                
  ├────┼─────┼────────────────────────────────────────────────────────┤                                
  │위탁처리│재활용    │원형 재사용[2001], 수리·수선 재사용[2002], 원료 제조[2003], 직접 제품제조[2004], 농업생산활동에 사             │                                
  │        │          │용[2005], 토질개선에 사용[2006], 성토재·복토재 등으로 사용[2007], 직접 에너지회수[2008], 연료·                │                                
  │        │          │고형연료제품 제조[2009], 중간가공폐기물 제조[2010]                                                              │                                
  │        ├─────┼────────────────────────────────────────────────────────┤                                
  │        │중간처분  │일반소각[2101], 고온소각[2102], 열분해[2103], 고온용융[2104], 압축[2105], 파쇄·분쇄[2106], 절단[2107],         │                                
  │        │          │용융[2108], 증발농축[2109], 유수분리[2110], 탈수·건조[2111], 멸균·분쇄[2112], 고형화[2113], 안정화            │                                
  │        │          │[2114], 소멸화[2115], 중화[2116], 지방자치단체 소각[2117], 국가 소각[2118], 기타[2119]                          │                                
  │        ├─────┼────────────────────────────────────────────────────────┤                                
  │        │매립      │민간관리형 매립시설[2201], 민간차단형 매립시설[2202], 기타 매립시설[2204], 지방자치단체 매립시설[2205],         │                                
  │        │          │국가 매립시설[2206]                                                                                             │                                
  │        ├─────┼────────────────────────────────────────────────────────┤                                
  │        │해역배출  │[2300]                                                                                                          │                                
  └────┴─────┴────────────────────────────────────────────────────────┘                                
  ┌──────────┬────────────────────────────────────────────────────────┐                                
  │폐기물의 성질과 상태│고체상태=1, 액체상태=2                                                                                          │                                
  ├──────────┼────────────────────────────────────────────────────────┤                                
  │폐기물 운반차량 종류│트럭/컨테이너=1, 탱크로리=2, 기타=3                                                                             │                                
  └──────────┴────────────────────────────────────────────────────────┘                                
    비고: 국가 소각 및 국가 매립시설은 한국환경공단 또는 수도권매립지관리공사가 위탁받아 운영하는 시설을 말하고, 지방자치단체 매립시설은                                    
    지방자치단체에서 직접 또는 위탁하여 운영하는 시설을 말합니다.                                                                                                           
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