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Fillable Printable Blank Receipt Template

Fillable Printable Blank Receipt Template

Blank Receipt Template

Blank Receipt Template

Report InstructionsEQP5500 (Rev 12/14)
INSTRUCTIONS FOR COMPLETING FORM:
Michigan Department of Environmental Quality
Oce of Waste Management and Radiological Protecon
COMBINED SOLID WASTE LANDFILL WASTE RECEIPT REPORT INSTRUCTIONS
As required by Section 11507a of Part 115, Solid Waste Management, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended.
Failure to submit this form may result in enforcement actions pursuant to Sections 11546 or 11549 of Part 115.
Please save a copy of this form to an appropriate location on your computer to use for the entire fiscal year
(October 1 through September 30). The form must be maximized in order to view each tab located at the bottom of the spreadsheet. Click and
enter data under the appropriate tab (i.e., Part I – Facility Info; Part II – Waste Report Information for 1st Qtr; 2nd Qtr; 3rd Qtr; 4th Qtr; Waste Key;
and Waste Definition.) Once data is selected for each of the tabs, the information will self-populate where appropriate. Example: Waste data
information selected under the 1st Qtr tab will self-populate to the remaining quarter tabs. Captive facilities may enter data for each of the four
quarters, however, they are ONLY required to submit annual waste data information using the Part II - 4th Qtr tab. For any questions, please
contact the Department of Environmental Quality (DEQ) at the telephone number found on the bottom of the next page.
Part 115 requires record keeping and reporting for three related purposes:
1. Section 11507a of Part 115 requires all landfills to annually submit a report of the amount of solid waste received and
the amount of remaining disposal capacity at the landfill.
2. Section 11525 of Part 115 requires all landfills to make payments to their Perpetual Care Fund (PCF), at least
semiannually, based on waste received, until the fund reaches the maximum required fund amount.
3. Section 11525a of Part 115 requires all noncaptive landfills to make quarterly surcharge payments to the State of
Michigan based on waste received. All captive landfills are required to make annual payments.
This form has been revised to promote consistency among these three related obligations.
• Section 11507a of Part 115 requires all landfills to annually submit a report of the amount of solid waste received by the landfill during that year
and, to the extent possible, the origin of that waste by county, state, or country and the amount of remaining disposal capacity at the landfill. This
report is to be submitted to the DEQ and the county and municipality where the landfill is located. A landfill that is located in more than one county
or municipality (township, city, or village) should submit the report to all counties/municipalities where the landfill is located. This form will also be
used to determine compliance with Sections 11525 (PCF) and 11525a (Surcharge). The Surcharge for captive facilities is due on January 31st
annually for waste received from October 1 - September 30; while the Surcharge for noncaptive facilities is due quarterly on the following
schedule:
Quarter: Quarterly Reporting Period: Date Due:
1st Quarter October 1-December 31 January 31
2nd Quarter January 1-March 31 April 30
3rd Quarter April 1-June 30 July 31
4th Quarter July 1-September 30 October 31
• Landfill owners/operators are to complete the information (fill out light shaded areas), sign, and submit the form within 30 days of the quarter's end
for waste received during the previous quarter. NOTE: When viewing "on-screen," these are the green shaded areas; yellow shaded areas will
automatically calculate.
• Complete all sections of the form that apply to your landfill.
Part I - Facility Information
• All landfills must identify facility type as Type II; Type III or Type III Segregated; captive or noncaptive status of the landfill; and waste receipt at
gate reporting measurement information, landfills must identify either the facility reports in tons or the facility does not report in tons.
• A captive facility means a Type III landfill that accepts for disposal only nonhazardous industrial waste generated by the owner of the landfill or a
nonhazardous industrial waste landfill that disposes and permanently segregates each of the following materials, as specified in Section 11525(3) of
Part 115:
(a) Coal ash, wood ash, or cement kiln dust that is disposed of in a landfill that is used only for the disposal
of coal ash, wood ash, or cement kiln dust, or a combination of these materials, or that is permanently
segregated in a landfill.
(b) Wastewater treatment sludge or sediments from wood pulp or paper producing industries that is disposed
of in a landfill that is used only for the disposal of wastewater treatment sludge and sediments from wood
pulp or paper producing industries, or that is permanently segregated in a landfill.
(c) Foundry sand or other material that is approved by the department for use as daily cover at an operating
landfill, that is disposed of in a landfill that is used only for the disposal of foundry sand, or that is
permanently segregated in a landfill.
Report InstructionsEQP5500 (Rev 12/14)
Continued:
Click to go to the Waste Key tab.Click to go to Definition tab.
Please save a copy of this form to an appropriate location on your computer to use for the entire fiscal year
(October 1 through September 30). The form must be maximized in order to view each tab located at the bottom of the spreadsheet. Click and
enter data under the appropriate tab (i.e., Part I – Facility Info; Part II – Waste Report Information for 1st Qtr; 2nd Qtr; 3rd Qtr; 4th Qtr; Waste Key;
and Waste Definition.) Once data is selected for each of the tabs, the information will self-populate where appropriate. Example: Waste data
information selected under the 1st Qtr tab will self-populate to the remaining quarter tabs. Captive facilities may enter data for each of the four
quarters, however, they are ONLY required to submit annual waste data information using the Part II - 4th Qtr tab. For any questions, please
contact the Department of Environmental Quality (DEQ) at the telephone number found on the bottom of the next page.
Part 115 requires record keeping and reporting for three related purposes:
1. Section 11507a of Part 115 requires all landfills to annually submit a report of the amount of solid waste received and
the amount of remaining disposal capacity at the landfill.
2. Section 11525 of Part 115 requires all landfills to make payments to their Perpetual Care Fund (PCF), at least
semiannually, based on waste received, until the fund reaches the maximum required fund amount.
3. Section 11525a of Part 115 requires all noncaptive landfills to make quarterly surcharge payments to the State of
Michigan based on waste received. All captive landfills are required to make annual payments.
This form has been revised to promote consistency among these three related obligations.
• Section 11507a of Part 115 requires all landfills to annually submit a report of the amount of solid waste received by the landfill during that year
and, to the extent possible, the origin of that waste by county, state, or country and the amount of remaining disposal capacity at the landfill. This
report is to be submitted to the DEQ and the county and municipality where the landfill is located. A landfill that is located in more than one county
or municipality (township, city, or village) should submit the report to all counties/municipalities where the landfill is located. This form will also be
used to determine compliance with Sections 11525 (PCF) and 11525a (Surcharge). The Surcharge for captive facilities is due on January 31st
annually for waste received from October 1 - September 30; while the Surcharge for noncaptive facilities is due quarterly on the following
schedule:
Quarter: Quarterly Reporting Period: Date Due:
1st Quarter October 1-December 31 January 31
2nd Quarter January 1-March 31 April 30
3rd Quarter April 1-June 30 July 31
4th Quarter July 1-September 30 October 31
• Landfill owners/operators are to complete the information (fill out light shaded areas), sign, and submit the form within 30 days of the quarter's end
for waste received during the previous quarter. NOTE: When viewing "on-screen," these are the green shaded areas; yellow shaded areas will
automatically calculate.
• Complete all sections of the form that apply to your landfill.
Part I - Facility Information
• All landfills must identify facility type as Type II; Type III or Type III Segregated; captive or noncaptive status of the landfill; and waste receipt at
gate reporting measurement information, landfills must identify either the facility reports in tons or the facility does not report in tons.
• A captive facility means a Type III landfill that accepts for disposal only nonhazardous industrial waste generated by the owner of the landfill or a
nonhazardous industrial waste landfill that disposes and permanently segregates each of the following materials, as specified in Section 11525(3) of
Part 115:
(a) Coal ash, wood ash, or cement kiln dust that is disposed of in a landfill that is used only for the disposal
of coal ash, wood ash, or cement kiln dust, or a combination of these materials, or that is permanently
segregated in a landfill.
(b) Wastewater treatment sludge or sediments from wood pulp or paper producing industries that is disposed
of in a landfill that is used only for the disposal of wastewater treatment sludge and sediments from wood
pulp or paper producing industries, or that is permanently segregated in a landfill.
(c) Foundry sand or other material that is approved by the department for use as daily cover at an operating
landfill, that is disposed of in a landfill that is used only for the disposal of foundry sand, or that is
permanently segregated in a landfill.
Part II - Waste Report Information
• Data may be reported either in tons or in cubic yards of waste received. Please use the facility's primary reporting measurement, tons or cubic
yards (gate yards before compaction within the landfill). Also, each facility, to the extent possible, must provide an appropriate factor for conversion
between tons and cubic yards based on the "Type of Solid Waste" received. Conversion factors may vary between waste types. The conversion
factor for Municipal/Commercial Waste (MCW) is typically 3 cubic yards per ton. The conversion factor for Industrial Waste including ashes is
typically one cubic yard per ton. Conversion factors for other waste types will vary.
• Waste data should be reported, to the extent possible, by waste type for each place of origin. Origin of waste means the geographic location
where the waste was first generated; intermediate processing or handling locations such as transfer stations should not be listed as a place of
origin. Waste from Michigan sources must be reported by each county of origin. Waste coming from a transfer station must be reported by the
place of origin and not by the county where the transfer station is located. Waste from other states should be reported by each state of origin.
Waste from other countries should be reported by each country (or province) of origin. For example: A waste generated in Michigan County ABC
is transported to another state and then brought back into Michigan for disposal. The origin of this waste must be reported as Michigan County
ABC. It is the landfill's responsibility to correctly identify the origin of waste to the extent possible.
• It is requested that all waste be reported separately as either MCW: Municipal and Commercial; or Municipal Solid Waste Incinerator ash;
C&D: Construction and Demolition; Industrial Waste: Industrial Waste General; Coal ash; Wood ash; Cement Kiln Dust; Industrial Wastewater
Sludges; Other Sludges; Wood/Paper Sludges; Wood/Paper Sediments; Foundry Sand; Other Approved materials (ADC) or Other (materials not
listed on the form). Segregated waste types include one or a combination of the three categories identified per Section 11525(3) of Part 115, and
are only considered segregated for the purposes of the PCF payments when placed in a separate unit (cell); commingled industrial waste is not
segregated waste type. MCW waste is "residential like" waste only. Type II facilities accepting industrial waste types need to report the waste
types separately; commingled waste should be reported as MCW. All waste received at the landfill must be reported, including all materials used
as alternative daily cover, excluding inert materials. All Industrial Waste types not identified on the form including contaminated soils should be
reported as "Other." See the Waste Key and Definition tabs for further detail. Please mark all boxes that apply for each waste type.
• Provide capacity information when reporting 4th Qtr ONLY (total permitted capacity should be based on actual permitted capacity for the life of the
landfill), including estimated cubic yards remaining capacity at both the start and end of the fiscal year. As explained in the "NOTE" in Part I -
Facility Information, the "Cubic Yards" reported here are "air space" and will, therefore, not be the same as the yards reported in Part II - Waste
Report Information that is reported as, or converted to, "Gate Yards." Please also identify the estimated number of years of capacity for both the
start and end of the fiscal year.
• Table 1: The information inserted under "Part II" will be used to automatically calculate the “Surcharge Due” and a “PCF Deposit Estimate” for each
quarter. The Surcharge Due amount should be submitted to the DEQ Cashier’s Office as instructed in the form. Captive facilities Surcharge Due
will be calculated as each quarter is entered; however, the surcharge amount due will not be correct until the 4th quarter data is entered.
• The PCF Deposit Estimate is a quarterly estimate based on the Waste Report Information provided and is used to assist in consistency. However,
there should be correspondence between the annual total “estimate” and the annual deposit made to the PCF fund. The amount of the semiannual
deposits made to the facility’s PCF fund will be reported to the DEQin the annual report from the facility’s financial institution.
• Table 2: Please enter actual surcharge payments and PCF deposit amounts made, and indicate any corrections that were made to the amount of
waste received for previous quarters. Please make any necessary adjustments to the PCF or Surcharge payment in the current quarter.
(1) All changes and/or corrections must be made in the appropriate quarter tab located at the bottom of the spreadsheet, in
which the information was originally selected.
(2) The spreadsheet is designed to repeat waste information from each of the previous quarters. As indicated
above, information selected for the 1st Qtr will self-populate to each of the remaining quarters (i.e., 2nd Qtr;
3rd Qtr; and 4th Qtr). Similarly, information selected or that has self-populated from a previous quarter in
the 2nd Qtr will repeat in the 3rd Qtr; and the 3rd Qtr information selected or self-populated from a previous
quarter will repeat in the 4th Qtr tab. Therefore:
● If the facility received the same waste type with the same conversion factor, from the same origin as any
of the previous quarters; the facility should enter the amounts of waste in the same row.
● If the facility received a new waste type and/or has a different conversion factor, or is from a different
origin, the facility should enter the amounts of waste in a new row.
(3) Forward questions by contacting:
Christina Miller via telephone at 517-614-7426 or via e-mail at DEQ-solid-waste-forms@michigan.gov
Michigan Department of Environmental Quality
Oce of Waste Management and Radiological Protecon
COMBINED SOLID WASTE LANDFILL WASTE RECEIPT REPORT INSTRUCTIONS
Page 2 of 2
Report InstructionsEQP5500 (Rev 12/14)
(1) All changes and/or corrections must be made in the appropriate quarter tab located at the bottom of the spreadsheet, in
which the information was originally selected.
(2) The spreadsheet is designed to repeat waste information from each of the previous quarters. As indicated
above, information selected for the 1st Qtr will self-populate to each of the remaining quarters (i.e., 2nd Qtr;
3rd Qtr; and 4th Qtr). Similarly, information selected or that has self-populated from a previous quarter in
the 2nd Qtr will repeat in the 3rd Qtr; and the 3rd Qtr information selected or self-populated from a previous
quarter will repeat in the 4th Qtr tab. Therefore:
● If the facility received the same waste type with the same conversion factor, from the same origin as any
of the previous quarters; the facility should enter the amounts of waste in the same row.
● If the facility received a new waste type and/or has a different conversion factor, or is from a different
origin, the facility should enter the amounts of waste in a new row.
(3) Forward questions by contacting:
Christina Miller via telephone at 517-614-7426 or via e-mail at DEQ-solid-waste-forms@michigan.gov
Waste Type KeyEQP5500 (Rev 12/14)
WASTE TYPE KEY
Municipal & Commercial Waste (MCW)Industrial Waste (IW)Construction & Demolition Waste (C&D)
DescriptionReferenceDescriptionReferenceDescriptionReference
R 299.4102(c)11502(2)R 299.4101(l)
11503(13)R 299.4102(a)R 299.4102(g)
R 299.4103 (k)11502(7)11503(14)
R 299.4104(a) &11504(6)11503(12)11503(15)
11504(8)R 299.4103(d)11503(16)
R 299.4103(n)
R 299.4103(w)
R 299.4103(x)
R 299.4104(m)
R 299.4105(e)
11525(3)
Coal Ash
Wood Ash
CKD
Wastewater Sludge
Wood Sediment
Paper Sediment
Foundry Sand
Other Approved Material (ADC)
Click on "waste type" above for hyperlink to definition.
Commercial wasteAshesAsbestos
GarbageCement Kiln Dust (CKD)Construction and Demolition Waste
Household wasteCoal or Wood AshScrap Wood
Medical Waste (Regulated)Food Processing ResidualsTreated Wood
Municipal Solid Waste Incinerator AshFood Processing WasteWood
Industrial Waste
Liquid Waste
Low-hazard Industrial Waste
Papermill Waste
Sludge
Segregated Waste Types for Purposes of PCF:
Waste DefinitionsPage 5EQP5500 (Rev 12/14)
WASTE DEFINITIONS
Asbestos
Ashes
means the residue from the burning of wood, coal, coke, refuse, wastewater sludge, or other combustible materials.
Cement Kiln Dust (CKD)
means particulate material that is collected in air emission control devices which serve portland cement kilns.
Coal or Wood Ash
means either or both of the following:
Commercial waste
Construction and Demolition Waste
Food Processing Residuals
(a) Residuals of fruits, vegetables, aquatic plants, or field crops.
(b) Otherwise unusable parts of fruits, vegetables, aquatic plants, or field crops from the processing thereof.
Food Processing Waste
means solid wastes that result from processing fruits and vegetables for preservation by freezing, drying, or canning.
Garbage
Household waste
means any solid waste that is derived from single households, but does not include any of the following:
(i) Commercial waste; (ii) Industrial waste; (iii) Construction and demolition waste.
Industrial Waste
Liquid Waste
Low-hazard Industrial Waste
Medical Waste [R 299.4104(a)]
Medical Waste [11504(6)]
Municipal Solid Waste Incinerator Ashmeans the substances remaining after combustion in a municipal solid waste incinerator.
Papermill Waste
means all of the following waste that is generated by pulp or paper mills:
Click to go Back to Waste Key
means asbestos-containing waste material, as defined in 40 C.F.R 61.141 under the national emission standard for asbestos.
The definition of asbestos-containing waste material and related definitions are adopted by reference in R 299.4131.
(a) The reside remaining after the ignition of coal or wood, or both, and may include noncombustible materials, otherwise
referred to as bottom ash
(b) The airborne residues from burning coal or wood, or both, that are finely divided particles entrained in flue gases arising
from a combustion chamber, otherwise referred to as fly ash
means all types of solid waste generated by stores, offices, restaurants, warehouses, and other nonmanufacturing activities, but
does not include household waste from single residences, hazardous waste, and industrial wastes. Commercial waste includes
solid waste from any of the following:
(i) Multiple residences; (ii) Hotels and motels; (iii) Bunkhouses; (iv) Ranger stations; (v) Crew quarters; (vi) Campgrounds;
(vii) Picnic grounds; (viii) Day-use recreation areas.
means waste building materials, packaging, and rubble that results from construction, remodeling, repair, and demolition
operations on houses, commercial or industrial buildings, and other structures. Construction and demolition waste includes trees
and stumps which are more than 4 feet in length and 2 inches in diameter and which are removed from property during
construction, maintenance, or repair. Construction and demolition waste does not include any of the following, even if it results
from the construction, remodeling, repair, and demolition of structures:
(i) Asbestos waste; (ii) Household waste; (iii) Corrugated containerboard; (iv) Appliances; (v) Drums and containers; (vi) Any
aboveground or underground tank and associated piping, except septic tanks; (vii) Solid waste that results from any
processing technique which renders individual waste components unrecognizable, such as pulverizing or shredding, unless
the type and origin of such waste is known not to contain the wastes listed in paragraphs (i) to (vi) of this subdivision.
(c) Otherwise unusable food products which do not meet size, quality, or other product specifications and which were
intended for human or animal consumption.
means rejected food wastes including waste accumulation of animal, fruit, or vegetable matter used or intended for food or that
results from the preparation, use, cooking, dealing in, or storing of meat, fish, fowl, fruit, or vegetable matter.
means solid waste which is generated by manufacturing or industrial processes or originates from an industrial site and which is
not a hazardous waste regulated under part 111 of the act.
means any waste material that is determined to contain free liquids as defined by method 9095, the paint filter liquids test, as
described in the publication entitled "Test Methods for Evaluating Solid Wastes, Physical-Chemical Methods" SW-846, which is
adopted by reference in R 299.4133. For purposes of the act and these rules, liquid waste does not include industrial waste
sludges that are disposed of at a location other than a type II landfill.
means an industrial waste that has a low potential for groundwater contamination when managed in accordance with these rules.
Wastes that meet this definition are designated in R 299.4122.
means waste as defined in section 13825 of Act No. 368 of the Public Acts of 1978, as amended, being §333.13825 of the
Michigan Compiled Laws.
means that term as it is defined in part 138 of the public health code, Act No. 378 of the Public Acts of 1978, being sections
333.13801 to 333.13831 of the Michigan Compiled Laws.
(i) Wastewater treatment sludge; (ii) Bark and wood residue; (iii) Scrap paper; (iv) Lime mud and grit; (v) Rejects from
screens, cleaners, and pulp mills; (vi) Green liquor dregs; (vii) Other wastes that the department determines have similar
characteristics.
Waste DefinitionsPage 6EQP5500 (Rev 12/14)
WASTE DEFINITIONSClick to go Back to Waste Key
Pepertual Care Fund
Scrap Wood
means wood or wood product that is 1 or more of the following:
(b) Wood or wood product treated with creosote or pentachlorophenol.
(c) Any other wood or wood product designated as scrap wood in rules promulgated by the department.
Sludge
Treated Wood
means wood or wood product that has been treated with 1 or more of the following:
(b) Ammoniacal copper quat (ACQ).
(c) Ammoniacal copper zinc arsenate (ACZA).
(d) Any other chemical designated in rules promulgated by the department.
Wood
The owner or operator of a landfill that is used for the disposal of the following materials shall deposit into the perpetual care fund
7.5 cents for each ton or cubic yard or portion of a ton or cubic yard of the following materials that are disposed of in the landfill
after June 17, 1990:
a) Coal ash, wood ash, or cement kiln dust that is disposed of in a landfill that is used only for the disposal of coal ash, wood
ash, or cement kiln dust, or a combination of these materials, or that is permanently segregated in a landfill.
(b) Wastewater treatment sludge or sediments from wood pulp or paper producing industries that is disposed of in a landfill
that is used only for the disposal of wastewater treatment sludge and sediments from wood pulp or paper producing
industries, or that is permanently segregated in a landfill.
(c) Foundry sand or other material that is approved by the department for use as daily cover at an operating landfill, that is
disposed of in a landfill that is used only for the disposal of foundry sand, or that is permanently segregated in a landfill.
(a) Plywood, pressed board, oriented strand board, or any other wood or wood product mixed with glue or
filler.
means any solid or semisolid waste that is generated from a municipal, commercial, or industrial wastewater treatment plant,
water supply treatment plant, or air pollution control facility. “Sludge” also includes any other semisolid industrial waste.
means trees, branches, bark, lumber, pallets, wood chips, sawdust, or other wood or wood product but does not include scrap
wood, treated wood, painted wood or painted wood product, or any wood or wood product that has been contaminated during
manufacture or use.
Part I - Facility Info
EQP5500 (Rev 12/14)
Michigan Department of Environmental Quality
Office of Waste Management and Radiological Protection
COMBINED SOLID WASTE LANDFILL WASTE RECEIPT REPORT
PART I - Facility Information
LEGAL NAME OF FACILITYWASTE DATASYSTEM NUMBERREPORTING YEAR
2015-2016
SITE ADDRESS TOWNSHIPCOUNTY
SITE CITY / TOWNSHIPSTATEZIP CODE
FACILITY OWNERCAPTIVE
00
0
00
WASTE RECEIPT AT GATE:
DOES THIS FACILITY REPORT IN TONS?
0
FACILITY DOES NOT REPORT IN TONS
Report Capacity data in 4th Qtr ONLY
Cubic YardsEst. Years
yds.
yds.
yds.
Est. Capacity used during this reporting year:
yds.
SEE INSTRUCTION SHEET FOR COMPLETING FORM
Quarterly Reporting Period:
Amount of Waste ReceivedSurcharge Due
PCF Deposit Estimate
TonsCubic Yards
Q1:October 1 - December 31
0.0
tons
0.0
yds.
$ - $ -
Q2: January 1 - March 31
0.0
tons
0.0
yds.
$ - $ -
###
Q3: April 1 - June 30
0.0
tons
0.0
yds.
$ - $ -
###
Q4: July 1 - September 30
0.0
tons
0.0
yds.
$ - $ -
###
Total0.0
tons
0.0 yds. $ - $ -
###
Record the amount(s) actually submitted for each quarter:
Surcharge
PCF Deposit
Quarterly Reporting Period:Paid
Paid
Q1: October 1 - December 31
Q2: January 1 - March 31
Q3: April 1 - June 30
Q4: July 1 - September 30
Total $ - $ -
###
OPERATOR'S/OWNER'S SIGNATURE:
TITLE:DATE:
EMAILADDRESS:CONTACT TELEPHONE:
NAME TYPED or PRINTED:
Return completed Part I and worksheet(s) and the appropriate fee to the Cashiers Office each quarter.
E-MAIL AN ELECTRONIC COPY OF THE ENTIRE SPREADSHEET AFTER THE 4TH QUARTER TO:
DEQ-solid-waste-forms@michigan.gov
Make check or money order payable to:
STATE OF MICHIGAN
REMIT TO:DEPARTMENT OF ENVIRONMENTAL QUALITY
CASHIER’S OFFICE
P.O. BOX 30657
LANSING MI 48909-8157
As required by Section 11507a of Part 115, Solid Waste Management, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended.
Failure to submit this form may result in enforcement actions pursuant to Sections 11546 or 11549 of Part 115.
TELEPHONE
Total Permitted Capacity:
Est. Capacity at start of state fiscal year (October 1):
Est. Capacity at end of state fiscal year (September 30):
TABLE 1: Automatically calculated from the data recorded in PART II - Waste Report Information.
TABLE 2: Information directly inserted by facility.
If any corrections were made for a "quarter" after
the original submittal, please state so in the line
adjacent to the relative quarter.
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I further certify that I am fully authorized by the owner
and/or operator of the landfill to submit this report. Should the signatory find at any time after submittal of the requested information that any portion of the submittal certified as true is
false or misleading, the signatory shall immediately notify the DEQ providing any corrections, explanations, or additional information necessary.
NOTE: The "Cubic Yards"
reported here are "air space"
and will, therefore, not be the
same as the yards reported
on the attached sheet which
are in "gate yards."
TYPE III Segregated
Check Box 30
Check Box 44
NOTE: The "Cubic Yards"
reported here are "air space"
and will, therefore, not be the
same as the yards reported
on the attached sheet which
are in "gate yards."
TYPE IIINONCAPTIVE
Check Box 154
FOR DEPT. CASHIER'S OFFICE ONLY
TYPE II
Part I - Facility Info
EQP5500 (Rev 12/14)
FOR DEPT. CASHIER'S OFFICE ONLY
Part II -1st Qtr
EQP5500 (Rev 12/14)
PART II - Waste Report Information
LEGAL NAME OF FACILITYSITE CITY/ TOWNSHIPREPORTING YEAR
00
2015-2016
NO
Type of Solid WasteOrigin of Waste
Waste CategoryWaste Type
Segregated Waste?
Waste Origin
FACILITY REPORTS IN YARDSTOTAL
Yards
Factor
Tons
Yds.Q1
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000
Surcharge Amount Due = 0cubic yards0.12=
Is this a 'CAPTIVE' facility?:
Waste Origin
Category
x $ / cubic yard
Conversion factor: based on the "Type of Solid Waste" received.
• MCW - three ± cubic yards per ton as the conversion factor.
• Ashes - one ± cubic yard per ton as the conversion factor.
• Industrial Waste - one ± cubic yard per ton as the conversion factor.
• Other wastes: use conversion factors suitable for the waste received.
CURRENT QUARTER: 1st QTR
Captives do not need to make quarterly payments; captives need to submit
only the fourth quarter report with annual payment.
Part II - 2nd Qtr
EQP5500 (Rev 12/14)
PART II - Waste Report Information
LEGAL NAME OF FACILITY
SITE CITY/ TOWNSHIPREPORTING YEAR
0
02015-2016
NO
Type of Solid WasteOrigin of Waste
Waste CategoryWaste Type
Segregated Waste?
Waste Origin
FACILITY REPORTS IN YARDS1ST QTRTOTAL
Yards
Factor
Tons
YDSYds.
0000
Surcharge Amount Due = 0
cubic yards
0.12
=0
Is this a 'CAPTIVE' facility?:
Waste Origin
Category
CURRENT QUARTER: 2nd
QTR
x $ / cubic yard
Conversion factor: based on the "Type of Solid Waste" received.
• MCW - three ± cubic yards per ton as the conversion factor.
• Ashes - one ± cubic yard per ton as the conversion factor.
• Industrial Waste - one ± cubic yard per ton as the conversion factor.
• Other wastes: use conversion factors suitable for the waste received.
Captives do not need to make quarterly payments; captives need to submit
only the fourth quarter report with annual payment.
Part II - 3rd Qtr
EQP5500 (Rev 12/14)
PART II - Waste Report Information
LEGAL NAME OF FACILITYSITE CITY/ TOWNSHIPREPORTING YEAR
00
2015-2016
NO
Type of Solid WasteOrigin of Waste
Waste CategoryWaste Type
Segregated Waste?
Waste Origin
FACILITY REPORTS IN YARDS2nd QTR1st QTRTOTAL
Yards
Factor
Tons
Yds.Yds.Yds.
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0
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000
Surcharge Amount Due =
0
cubic yards
0.12
=$0.00
Is this a 'CAPTIVE' facility?:
Waste
Origin
Category
CURRENT QUARTER: 3rd QTR
$ / cubic yard
Conversion factor: based on the "Type of Solid Waste" received.
• MCW - three ± cubic yards per ton as the conversion factor.
• Ashes - one ± cubic yard per ton as the conversion factor.
• Industrial Waste - one ± cubic yard per ton as the conversion factor.
• Other wastes: use conversion factors suitable for the waste received.
Captives do not need to make quarterly payments; captives need to submit
only the fourth quarter report with annual payment.
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