3422-TP--FY16-17

T&P 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. Indicate types of waste processed at this facility. (Check all that apply)
Medical Waste
Construction and Demolition Waste Household Hazardous Waste
Landclearing and inert debris (LCID)
Yard WasteIndustrial Waste
Other (describe)
4. Indicate types of processes occurring at this facility. (Check all that apply)
Grinding, composting or mulching
Medical Waste treatment
Incineration
Recycling/Reuse Collection (if yes, indicate materials collected; check all that apply and provide tonnages)
Other activities (specify)
2. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
TREAT
&
PROCESS
State of North Carolina
Department of Environmental Quality
Division of Waste Management
TREATMENT & PROCESSING FACILITY
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.
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,
Cardboard-2 tons, etc.).
Carpet tons
Wood tons
Concrete/rubble/asphalt tons Gypsum/drywall tons
Cardboard tons Electronics tons
Other Metal tons
Other Plastic tonsShinglestons
Other (specify)
T&P 2017 Page 2
6. Total waste received 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,treatment and processing, or mixed waste processing facility indicate the COUNTY
LOCATION OF THE FACILITY. Please list ALL counties from which you received waste. 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
CERTIFICATION: I certify that the information provided is an accurate representation of the activity at this facility.
Signature:Date:
Name:
Phone Number:Email:
Title:
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
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: