2560-FM-BWM0055D
Form
Rev. 3/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
55D
Treatment, Storage, or Disposal Facility Quarterly Operations and Fee Report
A. General Information
TSD Facility EPA ID No.
No Hazardous Waste Handled This Quarter
Quarter
January-March
April-June
July-September
October-December
Year
Facility Name
New Name
Facility Mailing Address
New Address
Municipality
City
Borough
Township
(Name of Municipality)
County
Contact Person
Title
Contact Telephone Number
(
)
-
Extension
Contact eMail Address
B. Fee Computation
All weights must be expressed in tons rounded to the nearest one-tenth (0.1) ton.
1 Cu. Yd. = 1 Ton, 1 Ton = 2,000 Pounds, 1 Gallon = 8 Pounds, 1 kilogram = 2.2 Pounds
L
I
N
E
1
Waste Handled
This Quarter
2
Fee Rate
3
4
5
Fee Due
(line 1 x line 2)
Credit from
Previous
Overpayment
Net Fee Due
(line 3 - line 4)
a
b
c
d
e
Treatment
(tons)
Storage
(tons)
Disposal
(tons)
Incineration
(tons)
Recycle
(tons)
f
Exempt
Cleanup
(tons)
g
Total
(tons)
.
.
.
.
.
.
.
$5.00
$2.00
$12.00
$5.00
$0.00
$0.00
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
XXXX
Fee payment must be enclosed with report to avoid penalty for late payment.
C. Certification
I, the undersigned, certify under penalty of law (18 Pa. C.S.A. § 4904) that the information provided is true and
correct to the best of my knowledge, in formation and belief.
Name of Authorized Representative (Type or Print)
Signature of Authorized Representative
Date (mm/dd/yy)