2601-MSWLF-1997-FY16-17

MSW 2017 Page 1
MSW 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, 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.
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.)
2. Does the tip fee above include the $2.00 Solid Waste Tax?Yes No
5. Date Facility Last Surveyed:
7. Total Tons Disposed in Airspace Used (tons):
6. Airspace Used (cubic yards):
Airspace (Capacity): Questions in this section relate to all cells/units of the lined 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 daily, intermediate and final cover.
MUNICIPAL SOLID WASTE LANDFILL Facility Annual Report
For the period of July 1, 2016-June 30, 2017
3. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
4. How is your leachate transported to the waste water treatment plant? Sewer Connection Pump Truck N/A
8. Do you utilize any alternate daily cover at this facility? If so, please describe below.
Received
Recycled
Landfilled
Landfill Rate
For Internal Use Only:
MSW 2017 Page 2
State County Jul-Sept (Qtr1)Oct-Dec (Qtr2)Jan-Mar (Qtr3)Apr-Jun (Qtr4)Total
In-State Total
9. Total material RECEIVED (waste + recyclables) at this facility during the period of July 1, 2016, through June 30, 2017. Indicate tonnage received by COUNTY of waste origin. If waste was received from a transfer station, indicate the COUNTY LOCATION OF THE TRANSFER STATION.
State County Jul-Sept (Qtr1)Oct-Dec (Qtr2)Jan-Mar (Qtr3)Apr-Jun (Qtr4)Total
Out-of-State Total
North Carolina Sources
Outside of North Carolina Sources
Total Material Received (In-State + Out-of-State tons)
MSW 2017 Page 3
10. 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 and amount recycled (tons):
Material Tons Material Tons
Paper Concrete/rubble/asphalt
Plastic Pallets
Carpet Electronics
Cardboard Fluorescent Light Bulbs
Glass Used oil/oil filters
Aluminum Cans Wood (not yard waste)
Steel Cans Gypsum/Drywall
White Goods Other (specify):
Other Scrap Metal Other (specify):
Commingled Recyclables Other (specify):
Total Recycled Material
12. If required to file NC E-500K forms with NC Dept. of
Revenue, provide the four quarterly tonnages this facility
reported for fiscal year 2016-2017.
Waste/Material Tons
Total Tonnage Received (question 9)
Total Received
Materials Recycled (question 10)-
Total Tons Landfilled at this Facility =
Disposed Tons Exempt
from Taxation* (if any)-
Total Tonnage Subject to Disposal Tax =
Quarter Tons Reported
July 1 - September 30 (Qtr1)
October 1 - December 31 (Qtr2)
January 1 - March 31 (Qtr3)
April 1 - June 30 (Qtr4)
NC E-500K Tax Tonnage Total=
13. If you indicated that your facility disposed tons of waste materials that were exempt from taxation in Question 11*, please provide a description of any tax exempt tons disposed and explain any difference existing between Total Tonnage Subject to Disposal Tax and NC E-500K Tax Tonnage Total.
11. Input total amount of waste that was received, recycled, and that
is exempt from taxation (ex-sludge,biosolids). Subtract total
recycled material and total tax-exempt tons from total tonnage
received. This number should represent the amount of tons
subject to the solid waste disposal tax and thus should equal the
E-500K tax tonnage total on right.
Summary of Facility Activity NC Solid Waste Disposal Tax
MSW 2017 Page 4
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:
15. Comments, suggestions or notes:
14. 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:
Name:Certification type and expiration date:
Name:Certification type and expiration date:
MSW 2017 Page 5
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