Department of Energy & Environmental Protection Bureau of Materials Management & Compliance Assurance 79 Elm Street - 4th Floor Hartford, CT 06106-5127 Commercial GP Facility Receiving Ash Residue (Appendix B) Quarterly Solid Waste (SW) Reporting Form Name of Facility: Permittee: SW Permit #: Facility Location: Street: Town: State: Zip Code: `Phone: Mailing Address (if different from facility location): Facility-Commercial GP Authorized Appendices Appendix A; Appendix B; Appendix C; Appendix D; Appendix E; – Appendix F; Appendix G If this facility is authorized for more than one SW facility category Materials authorized in more than one facility – category must only be reported ONCE on ONE reporting form. Receipt and storage capacities are NOT cumulative. Does the facility have a scale? Yes No If Ash Residue is not weighed Please – describe method for estimating weight Reporting Quarter YEAR: QUARTER: APPENDIX B COMMERCIAL GP FACILITY- Part 1 Ash Residue Received – Part 1A Ash Residue Received from a CT REGIONAL SW FACILITY – ORIGIN QUARTER TOTAL NAME/LOCATION OF CT REGIONAL SW FACILITY from which Ash Residue was RECEIVED Tons Received Part 1B Ash Residue Received from – QUARTER TOTAL STATE OF ORGIN (direct haul) OR NAME/LOCATION OF OUT-OF-STATE REGIONAL SW FACILITY Tons Received
Department of Energy & Environmental Protection Bureau of Materials Management & Compliance Assurance 79 Elm Street - 4th Floor Hartford, CT 06106-5127 Commercial GP Facility Receiving Ash Residue (Appendix B) Quarterly Solid Waste (SW) Reporting Form Name of Facility: Permittee: SW Permit #: Facility Location: Street: Town: State: Zip Code: `Phone: Mailing Address (if different from facility location): Facility-Commercial GP Authorized Appendices – Appendix A; Appendix B; Appendix C; Appendix D; Appendix E; Appendix F; Appendix G If this facility is authorized for more than one SW facility category – Materials authorized in more than one facility category must only be reported ONCE on ONE reporting form. Receipt and storage capacities are NOT cumulative. Does the facility have a scale? Yes No If Ash Residue is not weighed – Please describe method for estimating weight Reporting Quarter YEAR: QUARTER: APPENDIX B COMMERCIAL GP FACILITY- Part 1 – Ash Residue Received Part 1A – Ash Residue Received from a CT REGIONAL SW FACILITY ORIGIN NAME/LOCATION OF CT REGIONAL SW FACILITY from which Ash Residue was RECEIVED QUARTER TOTAL Tons Received Part 1B – Ash Residue Received from STATE OF ORGIN (direct haul) OR NAME/LOCATION OF OUT-OF-STATE REGIONAL SW FACILITY QUARTER TOTAL Tons Received
CommercialGP_Appendix_B_Fillable_Form_AshResidue.docx