Annual Report Drop Box

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ANNUAL REPORT
DROP BOX
FACILITY NAME:
CALENDAR YEAR OF
PERMIT NUMBER:
FACILITY ID:
REPORT:
FACILITY LOCATION (street address):
COUNTY:
FACILITY CONTACT (name):
FACILITY PHONE:
FACILITY CONTACT MAILING ADDRESS (if different):
FACILITY CONTACT PHONE (if
FACILITY CONTACT EMAIL:
different):
Did you operate in _______?
Yes If yes, proceed to next section and complete the form.
No If no, answer the following questions, sign and date the last page, and submit. This completes your reporting obligations.
When did you stop operations? ____________________________________________
Do you plan to restart?
No
Yes When? ______________________________
PLEASE CHECK IF RECEIVED
AMOUNT RECEIVED
Please check:
Cubic Yards or
Tons
Municipal/Commercial Solid Waste
Construction/Demolition Waste
Landclearing Debris
Industrial Waste
Inert Waste
Wood Waste
Yard Debris
Ash (other than special incinerator ash)
Appliances
Tires
Other (specify):
Other (specify):
Total
ECY 040-170 (12/10)
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