92V_CarolinaTree_LCID_AFR14-15

LCID 2015 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:
tons
cubic yards
LCID State of North Carolina
Department of Environment and Natural Resources
Division of Waste Management
LAND CLEARING & INERT DEBRIS
LANDFILL
Facility Annual Report
For the period of July 1, 2014-June 30, 2015
According to (G.S. 130A-309.09D(b)) completed forms must be returned by August 1, 2015 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.
92V-LCID
Carolina Tree Debris 92V-LCID
1417 Old Watkins Road
Raleigh
North Carolina 27616
Wake
North Carolina
Thomas Butler
[phone]
[e-mail]
N/A price depends on truck size (number of axles and body length)
304
52
Monday - Friday (8AM-5PM)
N/A
Thomas Butler
[phone] [e-mail]
Dennis Shackelford
225 Green Street, Suite 714
Fayetteville, NC 28301
phone: [phone] email: [e-mail]
DocuSign Envelope ID: 026E246F-493A-481A-8657-3EF2D4A062C6


LCID 2015 Page 2
Instructions:
NC DENR
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 Dwellings 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 Potable 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 Bodies 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 Dwellings 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
92V-LCID
Carolina Tree Debris 92V-LCID
1417 Old Watkins Road
Raleigh North Carolina 27616
Jul 30, 2015Madeline German
[phone] [phone] [e-mail]
~60 based on aerial photo
~375 ~570 ~790
N/A
N/A
3 (1 creek, 2 ponds)
~250 ~350 ~375
Harris Creek, unnamed ponds
Distances are constant from year to year, current distances estimated for Wake County GIS 2013 aerial photo. Tonnage
is based on estimates of tonnage with 3558 trucks of various sizes received at site with assumed density of 0.35 tons per
cubic yard.
DocuSign Envelope ID: 026E246F-493A-481A-8657-3EF2D4A062C6