Form SFN53326 "Inert Waste Facility Annual Report" - North Dakota

What Is Form SFN53326?

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

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the North Dakota Department of Health;
  • 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 printable version of Form SFN53326 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN53326 "Inert Waste Facility Annual Report" - North Dakota

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INERT WASTE FACILITY ANNUAL REPORT
Telephone: 701.328.5166
NORTH DAKOTA DEPARTMENT OF HEALTH
Fax: 701.328.5200
DIVISION OF WASTE MANAGEMENT
Website: www.ndhealth.gov/wm
SFN 53326 (01/2017)
1. Facility Information
Facility Name:
Owner/Operator Name:
Telephone Number:
Facility Mailing Address:
City:
State:
ZIP Code:
Email Address:
Facility Location Address:
Permit Number:
2. Calendar Period covered by Report (use Jan 1-Dec 31; reports are due on March 1)
From Month:
To Month:
Year:
3. Annual Quantity of each Waste Category Received (Use monthly total logs):
PLEASE INDICATE IF AMOUNT IS IN TONS(T), CUBIC YARDS(YDS), OR UNITS(U)!
Month
Yard Waste
White Goods
Concrete/Asphalt
Burnable
Tires
Other
T/YDS
T/U
T/YDS
T/YDS/U
T/YDS/U
T/YDS
January
February
March
April
May
June
July
August
September
October
November
December
TOTALS:
4. Explain Any Occurrences of Noncompliance:
5. Discuss Any Construction or Closure Activities:
INERT WASTE FACILITY ANNUAL REPORT
Telephone: 701.328.5166
NORTH DAKOTA DEPARTMENT OF HEALTH
Fax: 701.328.5200
DIVISION OF WASTE MANAGEMENT
Website: www.ndhealth.gov/wm
SFN 53326 (01/2017)
1. Facility Information
Facility Name:
Owner/Operator Name:
Telephone Number:
Facility Mailing Address:
City:
State:
ZIP Code:
Email Address:
Facility Location Address:
Permit Number:
2. Calendar Period covered by Report (use Jan 1-Dec 31; reports are due on March 1)
From Month:
To Month:
Year:
3. Annual Quantity of each Waste Category Received (Use monthly total logs):
PLEASE INDICATE IF AMOUNT IS IN TONS(T), CUBIC YARDS(YDS), OR UNITS(U)!
Month
Yard Waste
White Goods
Concrete/Asphalt
Burnable
Tires
Other
T/YDS
T/U
T/YDS
T/YDS/U
T/YDS/U
T/YDS
January
February
March
April
May
June
July
August
September
October
November
December
TOTALS:
4. Explain Any Occurrences of Noncompliance:
5. Discuss Any Construction or Closure Activities:
SFN 53326 (1-2017)
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OPTIONAL ANNUAL INFORMATION:
Inclusion of the following information may or may not be required by your permit, but reporting where possible is encouraged. The inclusion of
this information helps the Department more accurately track current waste trends in the state. Occasionally, this information is requested by
the public, survey groups and other state and federal agencies. Any information your facility can volunteer is greatly appreciated.
6. Waste Flow:
Amount of inert waste annually imported from out-of-state (indicate tons or cubic yards): _________________
Source of inert waste annually imported (indicate state(s) waste was generated from): __________________________________
7. Composting (if applicable):
Amount of compostable material added to the composting unit (indicate tons or cubic yards, if unknown say yes): ________________
Amount of finished compost material removed from composting unit (indicate tons or cubic yards, if unknown say yes): __________
8. Recycling (if applicable):
Only include amount that was removed for recycling or reuse from the corresponding unit at the facility.
PLEASE INDICATE IF AMOUNT IS IN TONS(T),CUBIC YARDS(YDS), OR UNITS(U)!
Concrete/Asphalt
___________________(T/YDS)
Wood Waste
___________________(T/YDS)
Trees/Branches
___________________(T/YDS)
Tires
___________________(T/YDS/U)
Electronics
___________________(T/U)
Scrap Metal
___________________(T/YDS)
Other (see below)
___________________(T/YDS/U)
Please list any other materials your facility has recycled over this annual report period and amounts (if possible):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
9. Landfill Capacity:
Estimated capacity of total cubic yards remaining for permitted disposal area: ______________________________________
10. Operations:
Average tipping fee for inert waste ($/ton): _______________________________
11. Name, Date, and Signature of Preparer:
Print Name:
Date (month/day/year):
Signature:
Send completed form to: ND Dept. of Health, Division of Waste Management, 918 E. Divide Ave., 3rd Fl., Bismarck, ND 58501-1947
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