Department of Energy & Environmental Protection Bureau of Materials Management & Compliance Assurance 79 Elm Street - 4th Floor Hartford, CT 06106-5127 COMMERCIAL GENERAL PERMIT Notifier/Tier I Operator - Annual Reporting Form Are you reporting as a: SOLID WASTE Notifier (First Time Notifier? Yes No) or MANAGEMENT CATEGORY Tier I Operator REPORTING ENTITY Name of Notifier/Operator: Location of Waste Aggregation Site: Street: Town: State: Zip code: Phone: Mailing Address (if different from above) REPORTING PERIOD: Fiscal Year ____ July ____ through June ______ Year Year Are incoming and outgoing wastes and recyclables weighed at the aggregation site? If Not - Please Describe Method for Estimating Tonnage Reported: PART 1: Waste or Recyclables Received from out-of-state - Does the aggregation site receive waste or recyclables generated out-of-state? If yes, Complete Part 1 (If if no skip to Part 2. service vehicles deliver CT and out-of-state waste mixed together- please try to estimate percentage from out-of-state); Type of Out-of-state Waste or Recyclable Received Tons Received JUL-DEC Tons Received JAN-JUN Fiscal Year Tons Received Year ____ Year _______ PART 2: Quantities (Tons) of Solid Waste Transferred from the Aggregation Site to Destinations other than a CT Permitted or CT Authorized Solid Waste Facility (e.g. transferred directly to a market such as a manufacturer, paper mill or transferred directly to an out-of-state destination, etc.) Any item which is burned as a fuel (except for waste oil), or is eventually incinerated or landfilled should be recorded as disposed and not as recycled. Part 2a - Solid Waste Transferred from the Aggregation Site to Out-of-State Disposal Destinations (e.g. waste-to-energy facilities, incinerators or landfills, etc.) Waste Sent To Out-Of-State Disposal Destinations Name And Location of Out-of-State Disposal Type Of Disposal Destination (e.g. landfill, Fiscal Year JUL to DEC JAN to JUN Type of Waste Total incinerator, out-of-state transfer station, Destination to which Waste Was Transferred Year:_____ Year: _____ Disposed out-of-state aggregation site, etc.) Tons Disposed
Department of Energy & Environmental Protection Bureau of Materials Management & Compliance Assurance 79 Elm Street - 4th Floor Hartford, CT 06106-5127 COMMERCIAL GENERAL PERMIT Notifier/Tier I Operator - Annual Reporting Form SOLID WASTE MANAGEMENT CATEGORY Are you reporting as a: Notifier (First Time Notifier? Yes No) or Tier I Operator REPORTING ENTITY Name of Notifier/Operator: Location of Waste Aggregation Site: Street: Town: State: Zip code: Phone: Mailing Address (if different from above) REPORTING PERIOD: Fiscal Year ____ July ____ through June ______ Year Year Are incoming and outgoing wastes and recyclables weighed at the aggregation site? If Not - Please Describe Method for Estimating Tonnage Reported: PART 1: Waste or Recyclables Received from out-of-state - Does the aggregation site receive waste or recyclables generated out-of-state? If yes, Complete Part 1 (If service vehicles deliver CT and out-of-state waste mixed together- please try to estimate percentage from out-of-state); if no skip to Part 2. Type of Out-of-state Waste or Recyclable Received Tons Received JUL-DEC Year ____ Tons Received JAN-JUN Year _______ Fiscal Year Tons Received PART 2: Quantities (Tons) of Solid Waste Transferred from the Aggregation Site to Destinations other than a CT Permitted or CT Authorized Solid Waste Facility (e.g. transferred directly to a market such as a manufacturer, paper mill or transferred directly to an out-of-state destination, etc.) Any item which is burned as a fuel (except for waste oil), or is eventually incinerated or landfilled should be recorded as disposed and not as recycled. Part 2a - Solid Waste Transferred from the Aggregation Site to Out-of-State Disposal Destinations (e.g. waste-to-energy facilities, incinerators or landfills, etc.) Waste Sent To Out-Of-State Disposal Destinations Name And Location of Out-of-State Disposal Destination to which Waste Was Transferred Type Of Disposal Destination (e.g. landfill, incinerator, out-of-state transfer station, out-of-state aggregation site, etc.) Type of Waste Disposed JUL to DEC Year:_____ JAN to JUN Year: _____ Fiscal Year Total Tons Disposed
CommercialGP_Notifier_Or_Tier1_Annual_Rept_Form.docx