SOLID WASTE LAND DISPOSAL FACILITY QUARTERLY REPORT Please Print in Ink or Type State Form 51908 (R3/10-07) Questions? Call: (317) 233-4624 Indiana Department of Environmental Management A – GENERAL INFORMATION Facility Name: – Facility ID #: ( Facility Location: City State ZIP Facility Telephone Number ( Name of Person Filling Out Form: ) Quarter Being Reported: ) Office Telephone Number Jan – Mar Office Mailing Address of Person Filling Out Form: Company Address City State Apr – Jun REPORTS ARE DUE THE 15TH OF THE MONTH FOLLOWING EACH QUARTER See example on the back of this form Refer to “Waste Classification Guide” Quantities may carry two decimal places Tabulate all totals Number of operating days during quarter: (must equal total of all section B entries for this quarter) (a partial day counts as a full operating day) Waste Origin State abbr. County Name IDEM Use Only Municipal Solid Waste Disposed Oct – Dec 20 ZIP B – QUARTERLY SOLID WASTE TONNAGE REPORT Total tons of solid waste disposed during quarter: Jul – Sep Use supplemental pages if necessary Non-Municipal Solid Waste Disposed C/D Debris Foundry Coal Ash FGD Waste Other Reuse 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. TOTAL for Quarter (tons) (this page) Are supplemental page(s) attached?: YES NO C – CERTIFICATION This is to certify that I have personally examined and am familiar with the information in this and any attached documents. I am aware of the Department of Environmental Management’s requirements for this report. To the best of my knowledge, the submitted information is true, accurate, and complete. _____________________________________ Name of Operator (please print or type) ___________________________________ Signature of Operator (original required) ___________________ Date (month, day, year) American LegalNet, Inc. www.FormsWorkflow.com Instructions A – General Information: Please provide the information requested in this section. Provide the name, phone number, and office mailing address of the person filling out this form as accurately as possible, since this information is used for correspondence regarding this facility’s quarterly reports. B – Quarterly Solid Waste Tonnage Report: Complete one line for each county from which your facility received waste. This includes Indiana counties and outof-state counties. First, provide the state abbreviation and the name of the county where the waste originated (provide the country name for non-U.S. waste origins). Please list Indiana counties first in alphabetical order, then list out-of-state waste origins. If your facility received waste from a transfer station, please list the county in which the transfer station is located as the origin of that waste. If your facility is a captive site, enter the county in which the waste was generated as the waste origin. Next, record the tonnage of each type of solid waste that your facility disposed from each waste origin. Facilities required to install weighing scales must report weighed tonnages. Please refer to the “Waste Classification Guide” for assistance in categorizing the solid waste received by your facility. See Example Below Please tabulate all totals, however, don’t include the “Reuse” total in the final total. All weights must be expressed in tons rounded to the nearest ton. If additional pages are needed, please complete the appropriate supplemental page(s) and indicate that these pages are attached. Facilities not required to install weighing scales must use the following conversion factors for Municipal Solid Waste: 3.3 cu. yds of compacted waste = 1 ton 6 cu. yds. of uncompacted solid waste = 1 ton 1 cu. yd. of baled waste = 1 ton For Non-Municipal Solid Waste, sites without scales may use a more appropriate conversion factor based on the waste’s density. C – Certification: Please print or type the name of your facility’s operator, and have the operator sign and date the report form. The following is an example of how part B of the report form should be completed (Please note that all waste origins and disposal tonnages are hypothetical) Total tons of solid waste disposed during quarter: 47,703 (must equal total of all section B entries for this quarter) Waste Origin State abbr. 1. 2. 3. 4. 5. County Name IDEM Use Only IN Hamilton IN Marion IN Shelby IL Cook OH Paulding TOTAL for Quarter (tons) Municipal Solid Waste Disposed 8,480 22,256 1,793 342 251 33,122 Number of operating days during quarter: 76 (a partial day counts as a full operating day) Non-Municipal Solid Waste Received C/D Debris Coal Ash FGD Waste Other 1,950 Foundry 3,200 Reuse 8,000 1,350 81 1,431 7 8,000 1,950 3,200 7 (this page) PLEASE RETURN COMPLETED FORMS TO: Indiana Department of Environmental Management Office of Land Quality Data Services Section 100 N Senate Ave Indianapolis, IN 46204-2251 American LegalNet, Inc. www.FormsWorkflow.com SOLID WASTE LAND DISPOSAL FACILITY QUARTERLY REPORT (SUPPLEMENTAL PAGE) Please Print in Ink or Type State Form 51908 (R3/10-07) Questions? Call: (317) 233-4624 Indiana Department of Environmental Management A – GENERAL INFORMATION Facility Name – Facility ID #: Quarter Being Reported: Jan – Mar Apr – Jun Jul – Sep Oct – Dec 20 B – QUARTERLY SOLID WASTE TONNAGE REPORT (cont.) Waste Origin Non-Municipal Solid Waste Disposed Municipal IDEM Solid Waste State County C/D FGD Use abbr. Name Disposed Foundry Coal Ash Other Debris Waste Only Reuse TOTAL for Quarter (tons) (this page) TOTAL for Quarter (tons) (this + previous page) American LegalNet, Inc. www.FormsWorkflow.com