9401-INDUS-2008_FAR-FY17-18

Industrial LF 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 industrial waste (specify waste):
Landfilling of ash
Landfilling of construction and demolition waste
Landfilling of asbestos
Landfilling of sludge
Landfilling of other waste (specify):
IND 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, 2018, 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.
INDUSTRIAL WASTE LANDFILL
Facility Annual Report
For the period of July 1, 2017-June 30, 2018
4. What other activities occur at this facility? (check all that apply)
Scrap Tire Collection White Goods Collection Household Hazardous Waste CollectionRecycling/Reuse Collection
If you checked Recycling/Reuse Collection, please indicate the materials accepted: (check all that apply)
Paper Wood Concrete/rubble/asphalt Gypsum/drywall
Cardboard Glass Aluminum Cans Steel Cans
PETE (#1) Plastic HDPE (#2) Plastic Computer Equipment Televisions
Fluorescent lightbulbs Used oil/oil filters Other Metal Other Plastic
Other (specify)
Airspace (Capacity): Questions in this section relate to all cells/units of
the facility operated under the current 4-digit permit number
regardless of whether the cells/units are closed or are not contiguous
at the time of this report. Tonnage questions must be based on scale
records and cover the period between the opening date and the date of
the last survey unless another time period is approved. Airspace
measurements include weekly, intermediate and final cover.
5. Date Facility Last Surveyed:
7. Total Tons Disposed in
Airspace Used (tons):
6. Airspace Used (cubic yards):
2. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
(amount disposed in tons):
Industrial LF 2017 Page 2
8. Total waste landfilled at this facility during the period of July 1, 2017, through June 30, 2018. Indicate tonnage received by COUNTY of
waste origin. 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:

Shawn McKee 1646 Mail Service Center
Raleigh, NC 27699-1646
Telephone: [phone] Email: [e-mail]
Industrial LF 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