Loading...
HomeMy WebLinkAbout9217-TRANSFER-1994-FY16-17Transfer 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: