See the instructions on the reverse side. SOLID WASTE DISPOSAL FEE REPORT State Form 50413 (R2 / 1-06) Indiana Department of Environmental Management Form Approved by State Board of Accounts, 2006 Reporting Period Ending: June 30 December 31 (Check appropriate box.) Year: 20 (Indicate year.) A. Facility Information FACILITY NAME FACILITY ADDRESS CITY TELEPHONE # IDEM PERMIT # STATE COUNTY - ZIP B. Disposal Fee Calculation MUNICIPAL WASTE LANDFILLED NON-MUNICIPAL WASTE LANDFILLED CONSTRUCTION-DEMOLITION WASTE SOLID WASTE INCINERATED TOTAL TONS DELINQUENCY CHARGE (If applicable, see instructions.) 7 ADJUSTED FEES (If applicable, see instructions.) TONS x $0.10 = TONS x $0.10 = TONS x $0.10 = TONS x $0.05 = TOTAL FEES TOTAL FEES x 10% = TOTAL FEES + Delinquency Charge = 1 2 3 4 5 6 $ $ $ $ $ . . . . . $ . $ . C. Preparer Information NAME TELEPHONE # TITLE D. Owner/Operator Certification NAME ADDRESS CITY TELEPHONE # TITLE STATE ZIP Under penalties of perjury, I declare that I have examined this report and to the best of my knowledge it is true, correct, and complete. SIGNATURE OF OWNER/OPERATOR_____________________________________________DATE__________ (Original signature required on the form submitted to IDEM) E. Return Information Make checks payable to: Indiana Department of Environmental Management Mail completed form and fee to: Indiana Department of Environmental Management Cashier Office – Mail Code 50-10C 100 N Senate Ave Indianapolis, IN 46204 FOR OFFICE USE ONLY: Account # 2830-412700-100700 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management SOLID WASTE DISPOSAL FEE REPORT INSTRUCTIONS GENERAL INFORMATION Indiana Code 13-20-21-6 imposes a fee on the disposal of solid waste into a municipal landfill, a non-municipal landfill, a construction-demolition waste site, and an incinerator in Indiana. The disposal fee is $0.10 per ton for solid waste in a municipal waste landfill; $0.10 per ton in a solid waste non-municipal waste landfill; $0.10 per ton for solid waste in a construction-demolition waste site; and $0.05 per ton for solid waste incinerated. The owner or operator of the solid waste facility must remit the fees and file an accompanying disposal fee report with the Indiana Department of Environmental Management (IDEM) twice a year. The fee and report for the period January 1 through June 30 are due August 1 of the same year. The fee and report for the period July 1 through December 31 are due February 1 of the following year. The report must indicate the amount of solid waste disposed by the facility from all sources during the reporting period, including out-of-state waste imported to Indiana. The facility should use daily scale receipts and other waste intake records for the fee payment period to calculate the fee amounts. Facilities not required to use scales under 329 IAC 10-14-2 should use the conversion factors and quantification methods described in 329 IAC 10-14-2 (e). The solid waste disposal fee is separate from, and in addition to, the $0.50-per-ton solid waste management fee which is remitted monthly to the Indiana Department of Revenue. The fees must be remitted with their respective forms. The fees should not be remitted together. INSTRUCTIONS FOR COMPLETING THE FORM Part A. Facility Information In the space provided, designate the six-month period for which the report is being filed. Provide all facility information as requested. In the appropriate space, enter the facility operating permit number as issued by IDEM. Part B. Disposal Fee Calculation Lines 1 – 4: Step One. On the appropriate line, enter the total amount of solid waste disposed by your facility according to the method of disposal. The tonnages should be reported to the nearest whole ton. Step Two. Multiply the tonnage figure on each line by the per-ton fee indicated. Enter each result in the right-hand column, to the nearest one cent. Line 5: Step One. Add together the tonnage figures from Lines 1, 2, 3, and 4. Enter the total tons in the appropriate box. Step Two. Add together the fee amounts from Lines 1, 2, 3, and 4. Enter the total fees in the right-hand column, to the nearest one cent. Line 6: If the total fees are not postmarked within 60 days after the due date, a delinquency charge must be calculated. The charge is ten percent (10%) of the total fees. Multiply the total fees by 0.10 and enter the result, to the nearest one cent. Line 7: If the delinquency charge applies, add Line 6 to Line 5 and enter the result, to the nearest one cent. Note: A facility that is delinquent in payment of disposal fees may be liable for a civil penalty of up to $25,000 per day and may be subject to a revocation of the facility permit. Part C. Preparer Information AND Part D. Owner/Operator Certification Provide all information as requested. The form must contain an original signature on the signature line. The “date” signed, must also be entered. If you have any questions about this form, contact IDEM by calling Nick Staller at (317) 234-3478. American LegalNet, Inc. www.FormsWorkflow.com