Form CEM-4401 "Solid Waste Disposal and Recycling Report" - California

What Is Form CEM-4401?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-4401 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-4401 "Solid Waste Disposal and Recycling Report" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SOLID WASTE DISPOSAL AND RECYCLING REPORT
CEM-4401 (REV 01/2018)
Project Name
Type of Work
Ongoing
Final Annual
Report
Report
Contract Number
Co/Rte/PM
[Note: Separate reports needed for each calendar year]
Report for Calendar Year
Contractor Name
Phone Number
Fax
1
Street Address
City, State, Zip
Contractor Certification: I certify under penalty of perjury that the information provided in this form is complete and accurate.
Signature
Print Name and Title
Date of Report
*NOTE: Earth and rock material must not be reported as either waste material diverted from or disposed of in landfills.
NAME AND LOCATION OF RECYCLING OR DISPOSAL
TYPE OF MATERIAL
TYPE OF ACTIVITY
AMOUNT
AMOUNT
AMOUNT
FACILITY (OR ENTER "REUSED" FOR MATERIALS
(Enter a letter for each type on
(Enter one activity per line)
TAKEN TO
DIVERTED FROM
GENERATED
a separate line):
1 = Source - Separated Materials
LANDFILLS TO A
AND THEN
GENERATED AND REUSED ON THIS JOB)
LANDFILL
A = Asphalt Concrete;
Recycling
RECYCLING
REUSED ON THIS
(TONS)
C = Concrete;
2 = On-Site Reuse
FACILITY
JOB
M = Metal; D = Mixed Debris;
3 = Mixed Debris Recycling
(TONS)
(TONS)
W = Wood/Cleared Vegetation;
4 = Reuse of Salvageable Items
ƚ
O = Other [Please Describe]
5 = Disposal at Landfill or
Transfer to Station
*See note above
ƚ ƚ
6 = Other [Please Describe]
2
Describe Material:
ƚ
ƚ ƚ
Describe the Activity:
I have reviewed the information submitted in this report for completeness.
Resident Engineer's Name (Please Print)
Phone Number
3
Signature
Date
COPY DISTRIBUTION: Original - Resident Engineer
Copy - District Construction Office
Copy - District Recycling Coordinator
(http://www.dot.ca.gov/design/lap/landscape-design/reccon/dist_recyc_coord.html)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SOLID WASTE DISPOSAL AND RECYCLING REPORT
CEM-4401 (REV 01/2018)
Project Name
Type of Work
Ongoing
Final Annual
Report
Report
Contract Number
Co/Rte/PM
[Note: Separate reports needed for each calendar year]
Report for Calendar Year
Contractor Name
Phone Number
Fax
1
Street Address
City, State, Zip
Contractor Certification: I certify under penalty of perjury that the information provided in this form is complete and accurate.
Signature
Print Name and Title
Date of Report
*NOTE: Earth and rock material must not be reported as either waste material diverted from or disposed of in landfills.
NAME AND LOCATION OF RECYCLING OR DISPOSAL
TYPE OF MATERIAL
TYPE OF ACTIVITY
AMOUNT
AMOUNT
AMOUNT
FACILITY (OR ENTER "REUSED" FOR MATERIALS
(Enter a letter for each type on
(Enter one activity per line)
TAKEN TO
DIVERTED FROM
GENERATED
a separate line):
1 = Source - Separated Materials
LANDFILLS TO A
AND THEN
GENERATED AND REUSED ON THIS JOB)
LANDFILL
A = Asphalt Concrete;
Recycling
RECYCLING
REUSED ON THIS
(TONS)
C = Concrete;
2 = On-Site Reuse
FACILITY
JOB
M = Metal; D = Mixed Debris;
3 = Mixed Debris Recycling
(TONS)
(TONS)
W = Wood/Cleared Vegetation;
4 = Reuse of Salvageable Items
ƚ
O = Other [Please Describe]
5 = Disposal at Landfill or
Transfer to Station
*See note above
ƚ ƚ
6 = Other [Please Describe]
2
Describe Material:
ƚ
ƚ ƚ
Describe the Activity:
I have reviewed the information submitted in this report for completeness.
Resident Engineer's Name (Please Print)
Phone Number
3
Signature
Date
COPY DISTRIBUTION: Original - Resident Engineer
Copy - District Construction Office
Copy - District Recycling Coordinator
(http://www.dot.ca.gov/design/lap/landscape-design/reccon/dist_recyc_coord.html)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SOLID WASTE DISPOSAL AND RECYCLING REPORT
CEM-4401 (REV 01/2018)
INSTRUCTIONS
Section 1: To be completed by the contractor
Project Name: Give a brief description of the project, e.g., "Route 1 widening in Fort Bragg, CA"
Type of Work: Enter a general work description, e.g. "AC Grinding"
Ongoing Report: Checking this box means this is an annual report for a continuing project. More reports will follow this one.
Final Annual Report: Checking this box means this report is for the calendar year of contract acceptance
Contract Number: Enter District/EA
Co./Rte/PM: Enter County/Route/Post Mile
Report for Calendar Year: The calendar year for which data was collected - January 1 to December 31 [Note: This report is an annual report.
A separate report is needed for each calendar year]
Company Information: Contractor Name, Phone Number, Fax Number, Street Address, City, State and Zip
Contractor Certification: I certify under penalty of perjury that the information provided in this form is complete and accurate.
Contractor should verify the data entered on this form, then sign the report and print your name, title, and date.
Return this report to the resident engineer by January 15 of each calendar year or within 15 days of contract acceptance.
Section 2: To be completed by the contractor
To count towards diversion, "solid waste" is defined as including any solid waste which would normally be disposed of at a disposal facility
(PRC Section 41781 (b))
*NOTE: Earth and rock material must not be reported as either waste material diverted from or disposed of in landfills.
NAME AND LOCATION OF RECYCLING OR DISPOSAL FACILITY (or enter "Reused" for materials generated and reused on this job)
Each address should be checked as either landfills or recycler. When using a recycling facility that exists inside a landfill, check recycler and
do not check landfill. When the solid waste is generated and reused on the job, the word "Reused" should be entered in place of the address.
TYPE OF MATERIAL Enter a letter for each type on a separate line:
A = Asphalt Concrete, C = Concrete; M = Metal; D = Mixed Debris; W = Wood/Cleared Vegetation; O = Other
[Describe the material when "Other" is selected]
ƚ
TYPE OF ACTIVITY Enter a number for each activity one per line:
1 = Source-Separated Materials Recycling; 2 = On-Site Reuse; 3 = Mixed Debris Recycling; 4 = Reuse of Salvageable Items;
5 = Disposal at Landfill or Transfer to Station; 6 = Other [Describe the activity when "Other" is selected]
ƚ ƚ
AMOUNT TAKEN TO LANDFILL (Tons): Enter the amount of any solid waste, in tons, that is generated on this project and taken to a landfill.
AMOUNT DIVERTED FROM LANDFILLS TO A RECYCLING FACILITY (Tons): Enter the amount of any solid waste, in tons, that is
generated on this project and taken to a recycling facility.
Solid waste from this job that is used in other projects, given to other agencies (county, city, etc.) or given to private individuals for reuse will be
entered as taken to a recycling facility. In this case, check the activity as "Other" and describe who gets the solid waste in the row for other
activity. (e.g. given to county, city or developer)
AMOUNT GENERATED AND THEN REUSED ON THIS JOB (Tons): Enter the amount of any solid waste, in tons, that is generated on this
project and then reused.
TOTAL SOLID WASTE FROM EACH JOB SHOULD APPROXIMATE THE SUM OF THE THREE QUANTITIES ABOVE.
For calculating weights, some volume to weight conversions may be needed. These conversion factors may be found at the California
Resources Recycling and Recovery (CalRecycle) web site at:
http://www.calrecycle.ca.gov/LGCentral/Library/DSG/ICandD.htm
Section 3: To be completed by the resident engineer
I have reviewed the information submitted in this report for completeness.
Resident engineer please review the report. If the form is complete, sign and print your name, phone number, and date.
Discuss and resolve with the contractor any deficiency on the form. Email the signed form to the District Construction Office and District
Recycling Coordinator (http://www.dot.ca.gov/design/lap/landscape-design/reccon/dist_recyc_coord.html)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
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