TRANSFER STATION ANNUAL REPORT Please Print in Ink or Type State Form 51885 (R/5-06) Indiana Department of Environmental Management A – General Information Questions? Call: (317) 308-3040 Operating Permit No.: Facility Name: Facility Location: City ( ) Facility Telephone Number State Name of Person Filling Out Form: ( ) Office Telephone Number Office Mailing Address of Person Filling Out Form Company Address Year Being Reported: City B – Inspection Report Inspection Date: State -Complete the information below to the best of your knowledge Name of Person Who Conducted Inspection: Type of Waste Found: (circle one) special / infectious / hazardous description: Explain how the Suspect Waste was handled: (for example, include how waste was isolated, contained, stored, shipped, etc.) ZIP -Use supplemental pages as necessary Generator of Suspect Waste: Name Address City/State/ZIP Hauler of Suspect Waste: Name Address Place of Final Disposal: Name of Facility Inspection Date: City/State/ZIP Name of Person Who Conducted Inspection: City/State/ZIP Type of Waste Found: (circle one) special / infectious / hazardous description: Explain how the Suspect Waste was handled: (for example, include how waste was isolated, contained, stored, shipped, etc.) Generator of Suspect Waste: Name Address City/State/ZIP Hauler of Suspect Waste: Name Address Place of Final Disposal: Name of Facility City/State/ZIP City/State/ZIP Number of supplemental pages attached: 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, and belief, the submitted information is true, accurate, and complete. Name of Operator (please print or type) Signature of Operator (original required) Date American LegalNet, Inc. www.FormsWorkflow.com All Solid Waste Transfer Stations (located both within and outside of Indiana) that transport and dispose of waste at solid waste disposal facilities in Indiana must submit this annual report to the Indiana Department of Environmental Management by January 31 of each year. Directions for Completing the Annual Report Form Section A – General Information Provide the name of the transfer station, the operating permit number (may vary for transfer station located outside Indiana), and the location and telephone number of the transfer station. The person completing the annual report form needs to include his/her name and office telephone number. In addition, provide a mailing address for the person completing the form. Indicate the year being reported. Remember, the annual report forms are due on January 31 of each year and they document the previous year’s activities (for example, the form is due on January 31, 1995 and year being reported is 1994). Section B – Inspection Report This section is to be completed for each incident that suspect hazardous, special, and/or infectious waste was detected at the transfer station during the year being reported. If more than two incidents occurred, use the supplemental page (make copies of the supplemental page as needed). Mark the appropriate box under the right side of Section B, just above Section C, regarding us of supplemental pages. Be sure to complete the top portion of the supplemental pages(s). If a transfer station does not have an incident of suspect hazardous, special, or infectious waste during the year being reported, mark Section B “NA” (not applicable) and move to Section C. Complete section B for each incident that suspect hazardous, special, and/or infectious waste was detected at the transfer station during the year being reported. Provide the inspection date (the transfer station monitoring inspection date) that the incident occurred. The transfer station should have all of this information on the “Random Inspection/Overview Incident Report” forms. Indicate the name of the person conducting the random or overview inspection at the time the suspect waste was detected. Circle the type of waste found (either special, infectious, or hazardous waste) and note a description of the waste. For example, if asbestos was detected at the site, circle special waste and note the description as asbestos material. Provide a brief narrative description on how the suspect waste was handled, once it was detected. Also, complete the information on the final destination of the suspect waste, including the name and address of the final disposal facility. If the transfer station can determine the hauler of the suspect waste, the hauler should be asked who the generator of the suspect waste was. If the hauler can provide information on the generator or if the transfer station has other knowledge of the generator, that information should be supplied in the portion of Section B title “Generator of Suspect Waste”. If the transfer station does not have any information on the generator, write “unknown” in this space. If the transfer station is able to determine the hauler of the suspect waste, the portion of Section B titled “Hauler of Suspect Waste” should be completed. If the transfer station does not have any information of the hauler, write “unknown” in this space. Remember to check the appropriate box regarding use of supplemental pages. Section C – Certification Please print or type the name of the transfer station’s operator, and have the operator sign and date the report form. The annual report, with original operator signature, should be sent to the following address: Indiana Department of Environmental Management Office of Land Quality Agricultural & Solid Waste 100 N. Senate Ave. Indianapolis, IN 46204-2251 American LegalNet, Inc. www.FormsWorkflow.com