EPA/HD Use Only
Solid & Infectious Waste
CDD Fees From CDD Landfills
Postmark:
Monthly Combined CDD Disposal Fee Report Check ID:
Revenue #:
This form is for use by licensed CDD Landfills only Check #:
DO NOT use this form for CDD disposal at MSW landfills Rev Type: LFST5
Enter facility name and Core ID, reporting month and year, and yd3 and tn volumes. Use box at bottom right to signify if submittal is on-time, or late
(and how late, if applicable). Total fees due plus applicable late penalties will be calculated automatically.
Facility (CDD Landfills Only) Month:
Facility Core ID Year:
A. Disposal of construction & demolition debris by CUBIC YARDS
Volume EPA / Health Dist Fee ODNR Fee Ground Water Fee Total yd3 Fees
X $0.30/yd3 $ - X $0.50/yd3 $ - X $0.05/yd3 $ - $ -
B. Disposal of construction & demolition debris by TONS
Volume OEPA / Health Dist Fee ODNR Fee Ground Water Fee Total TN Fees
X $0.60/tn $ - X $1.00/tn $ - X $0.10/tn $ - $ -
C. Total disposal fees
Total EPA / HD Fee Total ODNR Fee Total GW Fee Grand Total
$ - $ - $ - $ -
I hereby certify that this statement is true and correct.
ORC 3714.07 requires report and fee submissions to be post-marked no
later than 30 after the last day of the month for which the fees were
Authorized Signature collected. Late fee submissions are subject to 10% penalty for each 30 days
or portion thereof that they are late.
Printed Name & Title
Report & payment on time? Yes
Subscribed and sworn before me this ________ If late, by how many days? 0
day of ___________________, 20___________. Late penalty (if applicable): n/a
Notary Public
Total Fees Due $ -
To ensure proper credit, submit this form and full payment to the issuer of the license for this facility.
If Licensed Issued by Local Health District If License Issued by Ohio EPA
Payable to: Treasurer, State of Ohio
Your Health Dist: Ohio EPA
Department L-2711
Send Payment to Local Health District Columbus, OH 43260-2711