Form DEP5032 "Environmental Remediation Fee Reporting and Submittal Form" - Kentucky

What Is Form DEP5032?

This is a legal form that was released by the Kentucky Energy and Environment Cabinet - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2002;
  • The latest edition provided by the Kentucky Energy and Environment Cabinet;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DEP5032 by clicking the link below or browse more documents and templates provided by the Kentucky Energy and Environment Cabinet.

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Download Form DEP5032 "Environmental Remediation Fee Reporting and Submittal Form" - Kentucky

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DEP Form Number 5032 (Rev. 12-02)
Commonwealth of Kentucky
Natural Resources and Environmental Protection Cabinet
ENVIRONMENTAL REMEDIATION FEE
REPORTING AND SUBMITTAL FORM
Permit Number:
Name of Facility:
94
Company Name:
Type Fee Code:
Address:
Address:
Quarter (Check One)
o
o
City:
KY
ZIP Code:
1st (Jan.–March)
3rd (July–Sept.)
o
o
2nd (April–June)
4th (Oct.–Dec.)
Please note name and address corrections above.
GENERAL INFORMATION: The Environmental Remediation Fee, established by KRS 224.43-500, is assessed at a rate
of $1.75 per ton. This form and payment of the fee are due on or before April 30, July 31, October 31, and January 30, for
fees collected during the prior quarter. Make checks payable to Kentucky State Treasurer. Contact the Division of Waste
Management, Natural Resources and Environmental Protection Cabinet, 14 Reilly Road, Frankfort, KY 40601, telephone
(502) 564-6716, for information regarding the Environmental Remediation Fee.
1. Is this facility a transfer station? ............................................................................
Yes
No
If yes, skip to line 3.
2. Total tons of waste disposed at this facility ...........................................................
3. Total tons of waste transferred out of state ............................................................
For facilities without scales, estimate tonnage as follows:
1 ton = 3 cubic yards of compacted waste or 5 cubic yards of
noncompacted waste.
4. Total tons of waste assessed (add lines 2 and 3) ....................................................
1.75
5. Environmental Remediation Fee per ton ...............................................................
$
6. TOTAL DUE (multiply line 4 by line 5) ...............................................................
$
CERTIFICATION
I, the undersigned, an owner or operator of the above-named facility, certify that I have examined this report and it is, to the best
of my knowledge and belief, a true, correct and complete report.
Printed Name
Signature
Title
(
)
Date
Telephone Number
Mail the completed form to Environmental Remediation Fee, P.O. Box 429, Frankfort, KY 40602-0429.
Make check payable to Kentucky State Treasurer.
DEP Form Number 5032 (Rev. 12-02)
Commonwealth of Kentucky
Natural Resources and Environmental Protection Cabinet
ENVIRONMENTAL REMEDIATION FEE
REPORTING AND SUBMITTAL FORM
Permit Number:
Name of Facility:
94
Company Name:
Type Fee Code:
Address:
Address:
Quarter (Check One)
o
o
City:
KY
ZIP Code:
1st (Jan.–March)
3rd (July–Sept.)
o
o
2nd (April–June)
4th (Oct.–Dec.)
Please note name and address corrections above.
GENERAL INFORMATION: The Environmental Remediation Fee, established by KRS 224.43-500, is assessed at a rate
of $1.75 per ton. This form and payment of the fee are due on or before April 30, July 31, October 31, and January 30, for
fees collected during the prior quarter. Make checks payable to Kentucky State Treasurer. Contact the Division of Waste
Management, Natural Resources and Environmental Protection Cabinet, 14 Reilly Road, Frankfort, KY 40601, telephone
(502) 564-6716, for information regarding the Environmental Remediation Fee.
1. Is this facility a transfer station? ............................................................................
Yes
No
If yes, skip to line 3.
2. Total tons of waste disposed at this facility ...........................................................
3. Total tons of waste transferred out of state ............................................................
For facilities without scales, estimate tonnage as follows:
1 ton = 3 cubic yards of compacted waste or 5 cubic yards of
noncompacted waste.
4. Total tons of waste assessed (add lines 2 and 3) ....................................................
1.75
5. Environmental Remediation Fee per ton ...............................................................
$
6. TOTAL DUE (multiply line 4 by line 5) ...............................................................
$
CERTIFICATION
I, the undersigned, an owner or operator of the above-named facility, certify that I have examined this report and it is, to the best
of my knowledge and belief, a true, correct and complete report.
Printed Name
Signature
Title
(
)
Date
Telephone Number
Mail the completed form to Environmental Remediation Fee, P.O. Box 429, Frankfort, KY 40602-0429.
Make check payable to Kentucky State Treasurer.