67F-LCID-2012-.pdf

LCID 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
Tipping Fee: $per
Tipping Fee: $per
2. Estimate the amount of waste taken in an average week at this facility?
3. How many weeks did you operate this year?
4. What are the hours/days of operation for this facility?
5. What is the acreage of the footprint of the waste on site as of June 30?Acre(s)
CERTIFICATION: I certify that the information provided is an accurate representation of the activity at this facility.
Signature:Date:
Name:Title:
Phone Number:Email:
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:
6. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
tonscubic yards
LCID State of North Carolina
Department of Environmental Quality Division of Waste Management
LAND CLEARING & INERT DEBRIS LANDFILL
Facility Annual Report
For the period of July 1, 2016-June 30, 2017
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.
LCID 2017 Page 2
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