Free A ­ GENERAL INFORMATION - Indiana

SOLID WASTE LAND DISPOSAL FACILITY QUARTERLY REPORT
State Form 51908 (R3/10-07)

Please Print in Ink or Type

Questions? Call: (317) 233-4624

Indiana Department of Environmental Management

A ­ GENERAL INFORMATION
Facility Name: Facility Location:
City State ZIP

Facility ID #:

­
Quarter Being Reported:

( (

) )

Facility Telephone Number

Name of Person Filling Out Form: Office Mailing Address of Person Filling Out Form:

Office Telephone Number

Jan ­ Mar Apr ­ Jun

Company

Address

REPORTS ARE DUE THE 15TH OF THE MONTH FOLLOWING EACH QUARTER
ZIP

Jul ­ Sep Oct ­ Dec

City

State

20
See example on the back of this form Refer to "Waste Classification Guide" Quantities may carry two decimal places Tabulate all totals

B ­ QUARTERLY SOLID WASTE TONNAGE REPORT
Total tons of solid waste disposed during quarter: 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)

Use supplemental pages if necessary

Waste Origin
State abbr.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

County Name

IDEM Use Only

Municipal Solid Waste Disposed

Non-Municipal Solid Waste Disposed
C/D Debris Foundry Coal Ash FGD Waste Other Reuse

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)

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. 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. 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.

B ­ Quarterly Solid Waste Tonnage Report:

See Example Below

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: Number of operating days during quarter:

47,703

76

(must equal total of all section B entries for this quarter)

(a partial day counts as a full operating day)

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)
(this page)

Municipal Solid Waste Disposed 8,480 22,256 1,793 342 251 33,122

Non-Municipal Solid Waste Received
C/D Debris Foundry Coal Ash FGD Waste Other Reuse

8,000 1,350 81 1,950 3,200 7

1,431

8,000

1,950

3,200

7

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

SOLID WASTE LAND DISPOSAL FACILITY QUARTERLY REPORT (SUPPLEMENTAL PAGE)
State Form 51908 (R3/10-07)

Please Print in Ink or Type

Questions? Call: (317) 233-4624

Indiana Department of Environmental Management

A ­ GENERAL INFORMATION
Facility Name Quarter Being Reported: Jan ­ Mar Apr ­ Jun Jul ­ Sep Facility ID #: 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)