4903TP-MWP-_FAR-FY17-18

MWP 2018 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. Are there SWANA or other certified operator(s) at this facility?Yes No
If yes, indicate the following:
Name:
Certification type and expiration date:
Name:
Certification type and expiration date:
Name:
Certification type and expiration date:
5. Indicate the type and quantity of material from recycling or recovery operations stockpiled on-site as of June 30, 2017 (e.g. Wood-3 tons,
Metal-5 tons, etc.).
2. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
MIXED
WASTE
PROCESS
State of North Carolina
Department of Environmental Quality
Division of Waste Management
MIXED WASTE PROCESSING FACILITY
Facility Annual Report
For the period of July 1, 2017-June 30, 2018
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.
4. What materials are recovered from waste stream at this facility? (check all that apply and provide total annual tonnage)
Paper tons
Wood tons
Cardboard tons Aluminum Cans tons
Steel Cans tons
PETE (#1) Plastic tons
HDPE (#2) Plastic tons Computer Equipment tons Televisions tons
Fluorescent lightbulbs tons Used oil/oil filters tons
Other Metal tons
Concrete/rubble/asphalt tons Gypsum/drywall tonsGlasstons Other Plastic tons
Shingles tons Other (specify)
MWP 2018 Page 2
6. Total material received at this facility during the period of July 1, 2017, through June 30, 2018. 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. Please indicate COUNTY and STATE, if received from another state.
Received from Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Total
Grand Total 7. Indicate the facility(s) that received your facility's non-recycled waste material:
NAME, PERMIT #, and LOCATION (city, state) of FACILITY Tons
TOTAL
Facility Type
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: