6801-HHW-2003_FAR-FY17-18

HHW 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:
2. Indicate type and quantity of material accepted for treatment and its destination.
Material Quantity (pounds or gallons)Treatment
Destination or Contractor responsible for
disposal (company and state)
Fluorescent Lightbulbs
Other Mercury-Containing
Material
Electronic Material
Flammable Solids
Oxidizing Material
Poisonous Material
Flammable Liquids
Corrosive Material
Batteries
Compressed Gases
Antifreeze, Used Oil, Filters
Paint, Latex
Paint, Alkyd
Other:
Other:
Other:
Total
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
HHW State of North Carolina
Department of Environmental Quality
Division of Waste Management
HOUSEHOLD HAZARDOUS WASTE
COLLECTION
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.
1. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
HHW 2018 Page 2
3. Total household hazardous waste receive at this facility during the period of July 1, 2017, through June 30, 2018. Indicate in Pounds
amount received by COUNTY of waste origin. 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
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. Are certified operator(s) employed at this facility?
If yes, indicate the following:Yes No
Certification type and expiration date:
Name:
Name:
Certification type and expiration date:
Total from #2:Difference between #2 and #3:
4. Number of participants who delivered materials to the HHW facility:
5. Does your facility accept waste from conditionally exempt small quantity generators (CESQG)? Yes No
If yes, do you charge for CESQG waste?Yes No
Reason for Difference between #2 and #3: