1910-STRUC-2015-FAR_FY2016-17.pdf

Structural Fill 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:
SF State of North Carolina
Department of Environmental Quality
Division of Waste Management
According to your permit, completed forms must be returned by August 15, 2017. If you have questions or require assistance in completing
this report, contact the Environmental Senior Specialist responsible for Coal Ash.
STRUCTURAL FILL Facility Annual Report
For the period of July 1, 2016-June 30, 2017
Airspace (Capacity): Questions in this section relate to all cells/units of
the 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 weekly, intermediate and final cover.
2. Date Facility Last Surveyed:
4. Total Tons Filled in
Airspace Used (tons):
3. Airspace Used (cubic yards):
1. Did your facility stop receiving coal combustion products during this past Fiscal Year? Yes No
If so, please report the date this occurred:
5. Notes or Comments:
Structural Fill 2017 Page 2
6. Total coal combustion product used as fill at this facility during the period of July 1, 2016, through June 30, 2017. Indicate tonnage received by COUNTY of origin of the fill. Please list ALL counties from which you received fill. 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:
REMINDER: According to your permit, this report must be sent to the Environmental Senior Specialist for Coal Ash.Please return your completed report to:
Shawn McKee 1646 Mail Service Center
Raleigh, NC 27699-1646 phone: [phone] email: [e-mail]
Structural Fill 2017 Page 3
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 Fill (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 Fill?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Fill?Feet Feet Feet
2.Are there Water Supply Wells Within 1,500 feet of the Edge of Fill?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Fill?Feet Feet Feet
3.Are there Community/Municipal Wells Within 1,500 feet of the Edge of Fill?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Fill?Feet Feet Feet
4.Are there Surface Water Features Within 1,500 feet of the Edge of Fill?Yes No
If Yes, how many?
What are the three closest distances from the Edge of Fill?Feet Feet Feet
Please list the names of the water bodies:
5.Is Public Water Available Within 1,500 feet of the Edge of Fill?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