2500-FM-BWM0160 Rev. 10/2009
Please Type or Print in Ink
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU WASTE MANAGEMENT
Act 101, The Municipal Waste Planning,
Recycling, and Waste Reduction Act
QUARTERLY HOST MUNICIPALITY BENEFIT FEE REPORT
A. General Information
1.
2.
Permit No.
January-March
April-June
July-September
October-December
Year
3. Facility Name
4. Facility Address
5. Location
Township
Borough
City
(Name of Municipality)
6. County
7. Contact Name
8. Contact Title
10. Operator Name
9. Contact Phone No.
11. Operator Address
B. Fee Computation
All weights must be expressed in tons rounded to the nearest 1/10 ton. 3 Cu. Yd. = 1 Ton, 1 Ton = 2,000 Pounds
Line
No.
Municipal
Waste
Residual
Waste
Sewage
Sludge
Processed Demolition/
Infectious Construction
1
Month 1
2
Month 2
3
Month 3
4
Total Waste
5
Fee Calculation @ $1.00 Ton
6
Preexisting Agreement Credit
7
Net Fee
8
Discount for Timely Payment (1% Discount if paid before the Due Date)
9
Penalty for Late Payment (5% Penalty for each month or part of month late)
10
C.
Month
Ash
Asbestos
TOTAL
- ($1.00 X TOTAL on Line 4 x % of area)
Net Fee Due (Payment MUST be enclosed with report to avoid penalty for late payment.)
(0.01 x Line 7)
$
(0.05 x Line 7 x Mos.)
$
$
Certification
This is to certify that I have personally examined and am familiar with the information in this and any attached documents.
I am aware of the Department of Environmental Protection’s requirements for this report. To the best of my knowledge,
information and belief, the submitted information is true, accurate and complete. I am aware that there are significant
penalties for submitting false information.
Name of Operator / Contact
Signature of Operator / Contact
Date (mm/dd/yy)
2560-FM-BWM0160
Instructions
Rev. 10/2009
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
Act 101, The Municipal Waste Planning,
Recycling, and Waste Reduction Act
Instructions for the completion of the Act 101, Quarterly Host Municipality Benefit Fee Report.
This form must be completed by operators of municipal waste landfill and resource recovery facilities. The operator must
file this report with each municipality within which the permitted area of the landfill or facility is located. Please submit
the completed form and your fee payment to the Host Municipality and a copy of the completed form to the
following address:
PA Department of Environmental Protection
Bureau of Waste Management
P.O. Box 8550
Harrisburg, PA 17105-8550
Section A.
General Information
Line 1.
Permit No. - Enter your facility’s DEP permit number.
Line 2.
Quarter - Check the box for the quarter for which you are reporting and enter the year.
Lines 3 and 4.
Facility Name and Address - Enter the name and site address of your facility.
Lines 5 and 6.
City, Borough, Township and County - Enter the name of the municipality, check the box
indicating the type of municipality and enter the name of the county in which the active portions of
your facility are located.
Lines 7, 8 and 9.
Contact Name, Title, and Phone No. - Enter the name, title, and phone number of the facility
person who is knowledgeable about the contents of this report. This person may or may not be
the same person who certifies this report.
Lines 10 and 11.
Operator Name and Address - Enter the legal name and mailing address of the person, firm,
public organization, or other entity which operates the facility described in this report. This may or
may not be the name and address of the facility.
Section B.
Fee Computation (All weights must be expressed in tons, rounded to the
nearest tenth of a ton. 3 cubic yards = 1 ton; and 1 ton = 2,000 pounds)
Lines 1, 2 and 3.
Monthly Totals - Enter the total tons you received for each type of waste specified on the form,
for each month of the quarter. Total each line across and enter the totals in the space provided to
the right of each line. These totals must equal the total amount of each type of waste received for
each month.
Line 4.
Total Waste - Enter the total tons from left to right for each type of waste received for the quarter.
The sum of tons across Line 4 must equal the sum of Lines 1, 2, and 3.
Line 5.
If your facility is located within one host municipality, multiply the TOTAL tons on Line 4 by the
$1.00 (or more) per ton Host Municipality Benefit Fee. If your facility is located within more than
one host municipality, you must multiply the TOTAL tons on Line 4 by $1.00 (or more) per ton
and multiply that result by the percentage of permitted area of your facility in the host municipality
for which you are reporting. Insert fee rate/ton if more than $1.00.
Line 6.
Preexisting Agreement Credit - Enter the amount paid this quarter to the host municipality
pursuant to a preexisting agreement with the host municipality. Any amounts paid by an operator
to a host municipality pursuant to a preexisting agreement shall be deducted from the fee.
2560-FM-BWM0160
Instructions
Rev. 10/2009
Line 7.
Net Fee - For preexisting agreements only, subtract Line 6 from the fee calculation on Line 5 and
enter the result on Line 7. If there is no preexisting agreement, enter the result from Line 5 on
Line 7.
Line 8.
Discount for Timely Payment - If your fee payment is timely, that is, postmarked on or before
the twentieth day of the month following the quarter for which you are reporting, multiply the dollar
amount on Line 7 by 1% (0.01) and enter the result on Line 8.
Line 9.
Penalty for Late Payment - If your fee payment is not timely as defined in the instructions for
Line 8, multiply the dollar amount on Line 7 by 5% (0.05) if the payment is not more than one
month late and enter the result on Line 9. If the payment is more than one month late, multiply
the dollar amount on Line 7 by 5% (0.05) per month and per fraction of a month for which the
payment is late and enter the result on Line 9. This penalty cannot exceed 25%. Late payments
of the benefit fee will also be subject to an interest charge calculated by the Host
Municipality, who will notify you of the amount of interest due.
Line 10.
Net Fee Due - If your fee payment is timely, subtract Line 8 from Line 7 and enter the result on
Line 10. If your fee payment is late, add Line 9 to Line 7 and enter the result on Line 10. The
result on Line 10 is the net fee due. Please make a check or money order for this amount and
submit this payment with this report to the Host Municipality. Send a copy of this report to:
PA Department of Environmental Protection
Bureau of Waste Management
P.O. Box 8550
Harrisburg, PA 17105-8550
Section C.
Certification - An operator / contact must print or type his/her name, and
sign and date the form. The copy of the form accompanying the fee
payment must bear an original (not stamped or photocopied) signature.