1303-TIRELF-1988-FY16-17

TireLF 2017 Page 1
Facility Name:Permit:
Physical Address
Street 1:
Street 2:
City:
State:Zip:
County:
Mailing Address
Street 1:
Street 2:
City:
State:Zip:
Primary Facility Contact Person
Name:
Phone:Fax:
Email:
Billing Contact Person
Name:
Phone:Fax:
Email:
1. Tipping Fee: $per Ton (Attach a schedule of tipping fees if appropriate.)
3. Indicate types of disposal activity occurring at this facility (Check all that apply).
Landfilling of residential waste
Landfilling of commercial waste
Landfilling of industrial waste
Landfilling of construction and demolition waste, please estimate percent of waste landfilled:%
Landfilling of land clearing and inert debris waste (limbs, brick, stumps)
Landfilling of asbestos
Landfilling of shredded or split tires
Landfilling of ash
Landfilling of other waste (specify):
2. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
TIRE
LF
State of North Carolina
Department of Environmental Quality
Division of Waste Management
According to G.S. 130A-309.09D(b), completed forms must be returned by August 1, 2017 and a copy of this report must be sent to the
County Manager of each county from which waste was received. If you have questions or require assistance in completing this report, contact
your Regional Environmental Senior Specialist.
TIRE LANDFILL Facility Annual Report
For the period of July 1, 2016-June 30, 2017
TireLF 2017 Page 2
4. Total total tires landfilled at this facility during the period of July 1, 2016 through June 30, 2017. Indicate tonnage received by
COUNTY of waste origin. If waste was received from a transfer station,treatment and processing, or mixed waste processing facility indicate
the COUNTY LOCATION OF THE FACILITY. DO NOT include waste diverted for recycling, reuse, mulching, or composting. Please list
ALL counties from which you received waste. Please indicate COUNTY and STATE, if received from another state.
Received from Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May June Total
Grand Total
CERTIFICATION: I certify that the information provided is an accurate representation of the activity at this facility.
Signature:Date:
Name:
Phone Number:Email:
Title:
REMINDER: According to G.S. 130A-309.09D(b), this report must be sent to the Regional Environmental Senior Specialist for your area and a copy of this report must be sent to the County Manager of each county from which waste was received.
Please return your completed report to:
TireLF 2017 Page 3
Instructions:
NC DEQ
Division of Waste Management - Solid Waste Section Risk Assessment Form
Facility Name:Permit:
Address:
City:State:Zip:
Date:Person completing Assessment:
Phone Number:Fax:Email:
Please indicate either Yes or No for each Receptor and Post Closure Maintenance question. Then please
determine the distance or distances for each Receptor from the Edge of Waste (using range finders and/or GIS
maps) and type that information into the form. Please attach additional information including GIS maps, lists of
potable well locations, etc.
Receptors
1.Are there Residential Structures Within 1,500 feet of the Edge of Waste?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Waste?Feet Feet Feet
2.Are there Water Supply Wells Within 1,500 feet of the Edge of Waste?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Waste?Feet Feet Feet
3.Are there Community/Municipal Wells Within 1,500 feet of the Edge of Waste?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Waste?Feet Feet Feet
4.Are there Surface Water Features Within 1,500 feet of the Edge of Waste?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Waste?Feet Feet Feet
Please list the names of the water bodies:
5.Is Public Water Available Within 1,500 feet of the Edge of Waste?Yes No
If Yes, how many of the Residential Structures noted above are connected?
Corrective Measures
6.Is there an active methane extraction system (blower, flare, etc.)?Yes No
7.Is there a passive methane extraction system (trench, vents in cap, flare, etc.)?Yes No
8.Is there groundwater remediation taking place on site?Yes No
If Yes, what is the specific remedial technology used?
Comments