9217-TRANSFER-1994-FY16-17

Transfer 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. 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:
2. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
Does the tip fee above include the $2.00 Solid Waste Tax?Yes No
TRANS State of North Carolina
Department of Environmental Quality
Division of Waste Management
TRANSFER STATION Facility Annual Report
For the period of July 1, 2016-June 30, 2017
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.
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 and amount collected: (check all that apply and provide tonnages)
Carpet tons
Wood tons
Concrete/rubble/asphalt tons Gypsum/drywall tons
Cardboard tons Electronics tons
Other Metal tons
Other Plastic tonsShinglestons
Other (specify)
5. 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.Quarter Tons Reported
July 1 - September 30
October 1 - December 31
January 1 - March 31
April 1 - June 30
Total
Transfer 2017 Page 2
6. Total waste received (INCLUDING WASTE TRANSFERRED AND RECYCLED) at this facility during the period of July 1, 2016, through June 30, 2017. Indicate tonnage received by COUNTY of waste origin. 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 7. Indicate the facility(s) that received your facility's transferred 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:
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: