Calendar Year: 2009
MISSISSIPPI DEPARTMENT OF ENVIRONMENTAL QUALITY
COMMERCIAL RUBBISH SITE ANNUAL REPORTING FORM
(Two copies of this completed form and the related information should be submitted for each commercial rubbish
site no later than February 28th each year. Each form should be neatly printed or typewritten.)
Permittee Federal Employee ID No.:
Facility Type: Class I Class II Solid Waste Permit #
Physical Address of Facility:
Certified Rubbish Site Operator: Operator Number: RSO-
Facility Contact Person:
Facility Mailing Address:
Email (if available):
Period of Operation during the Calendar Year: to
AGGREGATE WASTE INFORMATION
1. State law requires that each load of waste received for disposal be recorded and reported in units of tons.
Check the box below that most accurately describes how the tonnage was determined. (Check all that apply)
Weight Scales. The scales used are located on-site off-site. (Skip to number 3)
Converted each load from cubic yards using MDEQ conversion factors. (See number 2)
Other; did not convert each load or used an alternate conversion factor(s). (See number 2)
2. For those facilities that did not use weight scales and calculated tonnage by conversion, please describe the
manner in which tonnage was determined in the space below or on attached sheets. Sample calculations and
an indication of each conversion factor used should be provided.
3. List the total amount of waste that was received for disposal during the calendar year in units of tons:
Total tons of rubbish received for disposal during the calendar year
4. Provide a breakdown between in-state and out-of-state rubbish disposed of during the calendar year:
Tons of in-state rubbish Tons of out-of-state rubbish
<continues on back>
REMAINING LIFE ESTIMATE
5. Provide an estimate of the remaining disposal capacity and the remaining life of the rubbish disposal
facility. Provide an estimate for each category.
acres cubic yards years remaining
6. In the space provided below describe how these estimates were determined:
WASTE SOURCE INFORMATION
7. In the space provided or on an attached sheet, list the source of rubbish waste received by county of origin
with a clear indication of wastes originating from out-of-state counties.
8. Check the box that most accurately describes the disclosure statement status for the reporting facility during
the calendar year.
No changes have been made to the disclosure statement on file with MDEQ.
Updated disclosure statement is attached.
Updated disclosure statement has been submitted separately.
Disclosure statement is not applicable (for public agency such as a county or city).
To the best of my knowledge and belief, I certify that the information provided with this report, including
attachments, is true, accurate and correct.
Name (print): Date:
Mail completed annual report to:
MDEQ - Solid Waste Policy, Planning & Grants Branch
P.O. Box 2261
Jackson, MS 39225
Phone: (601) 961-5171 Fax: (601) 961-5785