APPLICATION INFORMATION FOR
REIMBURSEMENT FOR CERTIFIED HOST MUNICIPALITY INSPECTORS
UNDER SECTION 1102 OF
THE MUNICIPAL WASTE PLANNING, RECYCLING
AND WASTE REDUCTION ACT
(ACT 101 OF 1988)
AND SECTION 304 OF
THE HAZARDOUS SITES CLEANUP ACT
(ACT 108 OF 1988)
PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
Rev. 11/2015
PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
REIMBURSEMENT FOR CERTIFIED HOST MUNICIPALITY INSPECTORS
1.
2.
3.
Statutory Authority:

Reimbursements are authorized under Section 1933-1 of the Administrative Code of 1929
(71 P.S. 510-33), which authorizes payments for certain inspectors, as provided for in Section 1102 of the
Municipal Waste Planning, Recycling and Waste Reduction Act (Act 101 of 1988) and Section 304 of the
Hazardous Sites Cleanup Act (Act 108 of 1988).

All funds are allocated from the Recycling Fund authorized under Act 101 for municipal waste facilities, or
from the Hazardous Sites Cleanup Fund under Act 108 for hazardous waste facilities.
Basic Provisions:

Reimbursements from the Funds are available to any municipality that has a municipal waste landfill,
resource recovery facility, or commercial hazardous waste storage, treatment or disposal facility located
within its geographic borders.

Upon application from any municipality, the Department shall award reimbursements for authorized costs
incurred for the salary and expenses of up to two certified Host Municipality Inspector(s).

The reimbursement shall not exceed 50% of the approved costs of the certified Host Municipality
Inspector’s salary and approved expenses.

Reimbursement will be available only for work conducted by certified Host Municipality lnspectors who have
been designated in writing by the host municipality.

The Department has established and conducts a training program to certify Host Municipality Inspectors.
Attendance at such training course(s) and passing a written examination are mandatory for certification.

The Department may withhold reimbursement for falsification of information included or submitted in
support of the application or for omission of information required to be submitted with the application.
Application Procedures:

Host Municipalities should contact the Pennsylvania Department of Environmental Protection, Bureau of
Waste Management, P.O. Box 8471, Harrisburg, PA 17105-8471, (717) 787-9870, for additional
information and application forms.

Proof of payment of expenses must be submitted with the application and include, at a minimum:

a)
Form W-2 Wage and Tax Statement for the year reimbursement is requested.
b)
Copies of weekly/monthly activity records.
c)
Receipted itemized invoices.
d)
Proof of attendance at training courses, meetings, or functions.
The attached W-9 Form (Request for Taxpayer Identification Number and Certification) must be completed
and submitted with the reimbursement application.
Note: Municipalities do not have to submit an application if they are not claiming reimbursement.
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4.
Eligible costs for Certified Host Municipality Inspector reimbursement:
25 Pa. Code § 272.362 Eligible Costs
(a)
The grant shall be for 50% of the approved costs of the salaries and expenses of up to two certified Host
Municipality Inspectors.
(b)
Costs not approved for a grant include, but are not limited to:
(1)
Activities and expenses incurred by the inspectors that are not related to inspection of resource
recovery facilities or municipal waste landfills located in the municipality.
(2)
Administrative, management or clerical activities.
(3)
Office equipment and office maintenance.
(4)
Office supplies, duplicating and postage.
(5)
Clothing allowances.
(6)
Costs covered under the grant provided by § 272.371 (associated with independent review of
permit applications).
(7)
Costs incurred by the municipality or the inspector prior to certification, after decertification or while
on inactive status.
Examples of Expenses approved for 50% Reimbursement

Wages or salaries for not more than two Host Municipality Inspectors on any given day.

Activities and expenses related to inspection of operations:






Travel from host municipality to the facility
Pre-inspection activities (review of records, reports, correspondence, request forms, etc.)
Inspection activities
Post-inspection activities (preparation of report, follow-up with facility, PA DEP, and/or host
municipality)
Attending approved training and meetings
Approved training and meetings:




PA DEP-sponsored training or meetings on municipal waste operations and regulations,
commercial hazardous waste operations and regulations, and/or host municipality inspector
program
Municipality/Public meetings concerning facility operations
Pennsylvania Association of Host Municipal Inspectors (PAHMI) meetings (including annual dues)
Solid Waste Association of North America (SWANA)/Pennsylvania Waste Industries Association
(PWIA) meetings

Employer costs for social security, Medicare, workers' compensation, unemployment compensation, health
benefits, retirement benefits and other benefits provided by the municipality.

Fees associated with attending approved training courses or related meetings and functions required by the
Department including:



Lodging and subsistence associated with attending approved training or meetings outside a 50-mile
radius of both the host municipality inspector’s place of employment and residence
Mileage, parking, fares and tolls
Safety equipment (boots, gloves, rain gear, orange vest, shoes) required for conducting inspections.
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5.
6.

Monitoring equipment (methane gas meter, portable gas/hydrocarbon detector (to detect methane gas)
magnehelic gauge, dissolved oxygen meter, pH conductivity temperature meter, VOC monitor).

Monitoring costs (sample bottles, packaging, ice, laboratory analysis, sample shipping) camera, film,
binoculars.
Examples of items specifically excluded as eligible costs for a program include, but are not limited to,
the following:

Activities and expenses not related to inspection activities (administrative, management, or clerical
activities, other municipality responsibilities).

Office equipment (computers, desk, facsimile machines, printers, telephone, typewriter).

Office supplies (inspection record book, field record book, paper, pens, and printer cartridges).

Clothing (non-safety related clothing).

Vehicle purchase/rental.

Independent permit application processing and review activities covered by 25 Pa. Code § 272.231 or
35 P.S. § 6020.304(d).
Grant Limitations:

A reimbursement may not be awarded to any municipality that has failed to comply with the conditions set
forth in previously awarded grants, the grant requirements of Act 101 or Act 108, or the regulations
promulgated under either Act.

The Department's ability to provide reimbursement is contingent upon the availability of funds in the
Recycling Fund or the Hazardous Sites Cleanup Fund.
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2500-FM-BWM0211
Instructions
Rev. 11/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
INSTRUCTIONS FOR FILING APPLICATION FOR
REIMBURSEMENT OF CERTIFIED HOST MUNICIPALITY INSPECTORS
Please read all instructions carefully before completing the application. Failure to submit the required and supporting
documents could result in the delay or loss of reimbursement. Please print or type all information.
This application should be submitted to the Pennsylvania Department of Environmental Protection, Bureau of Waste
Management, P. O. Box 8471, Harrisburg, PA 17105-8471 (717-787-9870). The application must be postmarked by
March 31 to be eligible for reimbursement for costs incurred from January 1 through December 31 of the prior year.
SECTION A
Item 3 – Indicate which statute authorizes the reimbursement of costs associated with employing Host Municipality
Inspectors. If the facility being inspected is a municipal waste landfill or resource recovery facility, the statutory
authority is provided by Section 1102 of the Municipal Waste Planning, Recycling and Waste Reduction Act (Act 101
of 1988). If the facility is a commercial hazardous waste treatment, storage or disposal facility, the statutory authority
is provided by Section 304 of the Hazardous Sites Cleanup Act (Act 108 of 1988).
Item 4 – Enter the Municipality's Federal I.D. Number. This number must be provided in order for the application to
be processed.
Item 5 – Enter the year for which this application is being submitted.
SECTION B
All expenses must be itemized and supported by appropriate documentation, including copies of the Form W-2 Wage
and Tax Statements, cancelled receipts, billing reports/invoices, the unemployment contribution rate notice (Form
UC-657), etc. All expenses under each cost object should be totaled in the right-hand column under "Object Total."
Failure to provide all supporting documentation may impact the Department’s ability to reimburse the full
amount requested and delay the reimbursement.
Attach the "Monthly Activities and Travel Log" for the period for which you are requesting reimbursement. These
forms must be legible.
SECTION C
This affidavit must be signed by a local agency official and the terms must be accepted by checking the checkbox.
SECTION D
Provide the name, facility identification number (for municipal waste landfills and resource recovery facilities), U.S.
EPA identification number (for commercial hazardous waste treatment, storage and disposal facilities), location
address, mailing address, and telephone number of each municipal waste landfill, resource recovery facility, or
commercial hazardous waste treatment, storage or disposal facility operating within your municipality.
SECTION E
Enter the name, title, and telephone number of the responsible local official, other than the inspector, who is the
representative of the local agency.
SECTION F
Provide the name, address, and telephone number of each certified Host Municipality Inspector employed by your
municipality during the year for which you are requesting reimbursement. Indicate their dates of employment and
whether they are employees of your municipality or employed by a contractor to your municipality (e.g., a consulting
engineering company). Indicate the total hours each inspector worked during the reimbursement period and the
hourly rate of pay for each inspector.
W-9
Attach the completed W-9 Form, Request for Taxpayer Identification Number and Certification.
2500-FM-BWM0211 Rev. 11/2015
Application for Reimbursement
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
APPLICATION FOR REIMBURSEMENT
OF CERTIFIED HOST MUNICIPALITY INSPECTORS
Please read all instructions before completing. The application must be postmarked by March 31 to be eligible for reimbursement of
costs incurred from January 1 through December 31 of the prior year.
Section A – Municipality Information
1. Municipality:
2. Official Business Address:
PA
3. Statutory Authority:
Section 1102 of the Municipal Waste Planning, Recycling and Waste Reduction Act (Act 101 of 1988)
Section 304 of the Hazardous Sites Cleanup Act (Act 108 of 1988)
4. Federal I.D. Number:
5. For Calendar Year:
DEPARTMENT USE ONLY
All supporting documentation for the application is on file in the Bureau of Waste Management.
Vendor ID #:
Invoice Number:
Invoice Date:
SAP FUND
BUDGET
PERIOD
GENERAL
LEDGER
COST
CENTER
6600400
3522509000
INTERNAL
ORDER
For Act 101: 2009000000
20
35250000
For Act 108: 2007100000
TOTAL AMOUNT APPROVED:
Approved for Payment - Signature
Date
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2500-FM-BWM0211 Rev. 11/2015
Application for Reimbursement
Section B – Itemized Expenses for Certified Host Municipality Inspectors
Failure to provide all supporting documentation may impact the Department’s ability to reimburse the full
amount requested and delay the reimbursement
COST OBJECT`
EXPLANATION
AMOUNT
OBJECT TOTAL
1. Wages
TOTAL
2. Employer Costs (i.e., Social Security,
Workers’ Comp., Unemployment Comp.)
NOTE: Please be sure to include all supporting documentation for any employer
costs. For unemployment compensation, please provide a copy of Form UC-657, the
Pennsylvania Unemployment Compensation (UC) Contribution Rate Notice.
RATE
AMOUNT
TOTAL
3. Mileage:
miles @
cents/mile
Mileage:
miles @
cents/mile
TOTAL
4. Lodging
TOTAL
5. Subsistence
TOTAL
6. Other Expenses
TOTAL
EXPENSE TOTAL
Total Reimbursement Requested (0.5 x Expense Total)
DEPARTMENT USE ONLY
Technical Review
Date
Administrative Review
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Date
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Application for Reimbursement
Section C – Affidavit
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
MUNICIPALITY OF
I,
,
state that I am an Official of the Applicant and that
the information included in the Application and Documents submitted as a part of the Application are true and correct
to the best of my knowledge and belief. I understand that the submission of an Application, which I know to be
forged, altered or otherwise lacking in authenticity, with the intent to mislead a public servant in performance of
his/her official function, is an action punishable by law.
,
Signature and Title of Local Agency Official
Date
I hereby accept the terms described above.
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2500-FM-BWM0211 Rev. 11/2015
Application for Reimbursement
Section D – Facility Information
Provide the name and address of each municipal waste landfill, resource recovery facility, or commercial hazardous
waste treatment, storage or disposal facility operating within your municipality.
Facility Name
Facility or U.S. EPA ID Number
Facility Location Address
City
Facility Telephone
(
)
-
County
Facility Mailing Address
City
State
Zip
Section E – Local Agency Official Contact
Contact Person (Name and Title)
Telephone
(
)
Email
Section F – Certified Inspector Identification
Inspector #1 Name
Inspector #2 (if applicable) Name
Address
Address
City
Telephone (
State
)
Zip
-
City
State
Telephone (
)
Zip
-
Email
Email
Employed from
to
Employed at (check one):
Applicant
Contractor to Applicant
Name and Address of Contractor:
Employed from
to
Employed at (check one):
Applicant
Contractor to Applicant
Name and Address of Contractor:
Inspector #1
Total hours worked during period ............................................
Rate of pay per hour ................................................................
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Inspector #2
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Application for Reimbursement
Section F – Certified Inspector Identification (continued)
Inspector #3 (if applicable) Name
Inspector #4 (if applicable) Name
Address
Address
City
Telephone (
State
)
Zip
-
City
State
Telephone (
)
Zip
-
Email
Email
Employed from
to
Employed at (check one):
Applicant
Contractor to Applicant
Name and Address of Contractor:
Employed from
to
Employed at (check one):
Applicant
Contractor to Applicant
Name and Address of Contractor:
Inspector #3
Total hours worked during period ............................................
Rate of pay per hour ................................................................
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Inspector #4
2500-FM-BWM0211 Rev. 11/2015
Checklist for Reimbursement
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
CHECKLIST FOR HOST MUNICIPALITY
INSPECTOR REIMBURSEMENT APPLICATION
DID YOU:
Complete Sections A - F?
Complete and sign the Affidavit?
Include W-2 form or other documentation for wages?
Include documentation for social security, Medicare, workers’ compensation, unemployment
compensation, health benefits, retirement benefits and other benefits provided by the municipality?
Enter the rate for social security, Medicare, workers’ compensation, unemployment compensation, health
benefits, retirement benefits and other benefits provided by the municipality in the “Rate” column in
Section B?
Include completed monthly activities and travel log (mileage) or other documentation of host municipality
inspector’s activities?
Include documentation to substantiate travel, subsistence, training, safety equipment, monitoring
equipment/costs or other approved expenses?
Complete and include a W-9 Federal ID Form?
2500-FM-BWM0211 Rev. 11/2015
Instructions for Activities and Travel
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
INSTRUCTIONS FOR COMPLETING
THE MONTHLY ACTIVITIES AND TRAVEL LOG
1. This form is to be completed for each month worked during the year. Totals for hours worked, miles traveled,
subsistence expenses, lodging expenses, and miscellaneous expenses should be entered at the bottom of the
page in the appropriate box. The activity section must be completed for each day worked. The travel section
should be completed only when you are claiming reimbursement for travel, lodging, or subsistence expenses.
Only those activities and expenses associated with your authorized activities as a certified Host
Municipality Inspector should be listed. Reimbursement of travel expenses will be in accordance with the
Department's travel regulations as set forth in Management Directive 230.10, Commonwealth Travel Policy,
and Manual 230.1, Commonwealth Travel Procedures Manual June 17, 2009, or the current department travel
regulations or municipal rates, whichever are lower.
ACTIVITIES SECTION
DATE: Enter the day worked/paid. Each day worked/paid must be indicated on this form.
ACTIVITY SUMMARY: Briefly list the major activities undertaken during the day.
HOURS WORKED: List the total hours worked/paid on host municipality activities during the day. Total these
hours for the month and enter this figure at the bottom of the page.
TRAVEL SECTION
LEAVE (LV): Enter the time of day you left your home or workplace as it relates to travel expenses being
claimed.
RETURN (RET): Enter the time of day you returned to your home or workplace.
LOCATIONS: List the location(s) you traveled to and from.
MILES: List the miles traveled on a daily basis. Total these miles for the month and enter this figure at the
bottom of the page.
SUBSISTENCE: List each subsistence amount being claimed with its corresponding travel. Total these
subsistence expenses for the month and enter this figure at the bottom of the page. Show only those expenses
incurred by you, which are eligible for reimbursement.
LODGING: List any lodging expense incurred with its corresponding travel. Total these lodging expenses for
the month and enter this figure at the bottom of the page.
MISCELLANEOUS EXPENSES: List any miscellaneous travel expenses incurred (such as tolls, parking,
fares, etc.). Vehicle maintenance is not reimbursable. Total these expenses and enter this amount at the
bottom of the page.
2.
Attach supporting documentation for expenses claimed to the corresponding Activities and Travel Log.
Receipts for all subsistence, lodging, and miscellaneous expenses must be provided.
ACTIVITIES AND TRAVEL LOG EXAMPLE:
Date
4/29
Activity Summary
Public Meeting on Facility
No.
Hours
Worked
3
LV
7:00
RET
10:00
Locations
Lewisburg
Miles
20
Subsistence
Lodging
Miscellaneous
Expenses
2500-FM-BWM0211 Rev. 11/2015
Application for Activities and Travel
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
APPLICATION FOR REIMBURSEMENT FOR CERTIFIED HOST
MUNICIPALITY INSPECTOR’S MONTHLY ACTIVITIES AND TRAVEL LOG
Activity Report for
For the Month of
Name
Municipality
DAILY ACTIVITIES SECTION
DAILY TRAVEL SECTION
Date
Activity Summary
Number of Hours Worked
LV
RET
Locations
Miles
Subsistence
Lodging
Miscellaneous Expenses
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Application for Activities and Travel
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Application for Activities and Travel
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Application for Activities and Travel
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Application for Activities and Travel
DAILY ACTIVITIES SECTION
DAILY TRAVEL SECTION
Date
Activity Summary
Number of Hours Worked
LV
RET
Locations
Miles
Subsistence
Lodging
Miscellaneous Expenses
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TO
TA
LS ...........................................
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