DEP5033 Form - RLA - Municipal Solid Waste Collector and ...



|Kentucky Department for Environmental Protection |FOR OFFICIAL USE ONLY. |

|Division of Waste Management |DO NOT WRITE IN THIS SPACE |

|Recycling and Local Assistance Branch | |

|300 Sower Boulevard, Second Floor – Frankfort KY 40601 | |

|(502) 564-6716 | |

| | |

|Municipal Solid Waste (MSW) Collector and Recycler | |

|Registration and Report | |

|1. Reporting Year |      |

|2. County |      |

|3. City |      |

|4. Collector (Type) |☐ City Franchise Hauler |☐ City Permit Hauler |☐ Franchise Hauler |☐ Municipally Owned |

| |☐ Permit Hauler |☐ Private Hauler |☐ Recycler |☐ Transfer Station or Convenience |

| | | | |Center Self-Haul |

|5. Name of Collector |      |

|6. Doing Business As |      |

|7. Contact Person |Name:       |Title/Position:       |

| |Signature: |Date Submitted:    /   /    |

| |Mailing Address:       |City:       |

| |State:       |Zip Code:       |Email Address:       |

| |Phone Number: (   )   -     |Fax Number: (   )   -     |

|8. Routes/Coverage Area |      |

|9. Number of Households Served |      |

|10. Number of Businesses |      |Number of industrial facilities       |

|11. MONTHLY COST PER HOUSEHOLD – SOLID WASTE |

|Waste Pick-Up |Per Bag (Cost if Charged per Bag) |Rate For Low Income/Elderly |

|$      |$      |$      |

|12. TONNAGE OF MSW COLLECTED FOR DISPOSAL – SOLID WASTE |

|Amount Disposed in Tons |Disposal Facility/Transfer Station |Tipping Fees/Ton |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|TOTAL TONS |      |

|13. RECYCLING REPORTING |

| |

|13(a). Door-to-door |☐ Yes |☐ No |

|13(b). County Households County |Door-to-door recycling provided for:       |

|13(c). Average Monthly Cost |Curbside Recycling $      |Yard Waste Pick-Up $      |

| | | |

| | | |

|14. TOTAL AMOUNT OF RECYCLING MATERIALS |

|Recycling Materials |Quantity |

|Aluminum Cans |      |Tons |

|Antifreeze/Ethyl Glycol |      |Gallons |

|Asphalt |      |Tons |

|Cardboard |      |Tons |

|Cloth |      |Tons |

|Concrete |      |Tons |

|Electronic Scrap |      |Tons |

|Glass |      |Tons |

|Lead Acid Batteries |      |Each |

|Metal, Ferrous (Steel, White Goods) |      |Tons |

|Metal, Non-Ferrous (Aluminum, Copper, Scrap Brass, Stainless Steel) |      |Tons |

|Motor Oil |      |Gallons |

|Newsprint |      |Tons |

|Paint (Recycled/Reused Only) |      |Gallons |

|Paper, Mixed Residential |      |Tons |

|Paper, Office Mixed |      |Tons |

|Paper, Office White |      |Tons |

|Pesticide Containers |      |Tons |

|Plastic, #1 PET (Soft Drink Bottles) |      |Tons |

|Plastic, #2 HDPE (Milk Jugs) |      |Tons |

|Plastic, Mixed |      |Tons |

|Polystyrene (Styrofoam Products) |      |Tons |

|Printer Toner Cartridges/Inkjet Cartridges |      |Each |

|Sewage Sludge |      |Tons |

|Single Stream, Included Items:       |      |Tons |

|Steel Cans |      |Tons |

|Tires |      |Each |

|Other       |      |      |

|Other       |      |      |

|Other       |      |      |

GENERAL INSTRUCTIONS

Municipal Solid Waste (MSW) Collector and Recycler Registration and Report

Instructions provided are for DEP 5033, Municipal Solid Waste (MSW) Collector and Recycler Registration and Report. For any questions regarding any category, please call the Division of Waste Management’s Recycling and Local Assistance Branch at (502) 564-6716. This form must be completed by typing or printing legibly.

Important Note: This form is to be completed by all persons providing collection service, including collection for the purpose of recycling with the counties in which they provide service in accordance with KRS 224.43-315 (2) and 224.43-315 (2).

DEADLINE: Report to the County by February 1st.

Submit DEP 5033 form to: Kentucky Department for Environmental Protection

Division of Waste Management

Recycling and Local Assistance Branch

300 Sower Boulevard, Second Floor

Frankfort, KY 40601

(502) 564-6716

Section 1. Reporting Year: Enter the calendar year being reported.

Section 2. County: Enter the county where service is provided.

Section 3. City: Enter the city where service is provided.

Section 4. Collector (Type): Mark type of collector.

Section 5. Name of Collector: Enter name of company who prepares report.

Section 6. Doing Business As: Enter the agency interest identification.

Section 7. Contact Person: Enter the name of individual who prepares this report; date signed, mailing address, email address, phone and fax numbers.

Section 8. Routes and Coverage Area: Enter the routes and coverage area.

Section 9. Number of Households Served: Enter the number of households served.

Section 10. Number of Businesses: Enter the number of businesses from which MSW is collected for disposal or recycling. Enter how many

of these establishments are industrial facilities.

Section 11. Monthly Cost per Household (for Solid Waste Collection): Enter the average monthly cost per household for solid waste

collected for disposal by your company from the county.

Section 12. Tonnage of MSW Collected for Disposal (for Solid Waste Collection): Enter the amount of tons collected for disposed by your

company, disposal facility/transfer station, and tipping fees per ton.

Section 13. Recycling Reporting (for Recycling): Mark yes or no.

(a). Door-to-door Recycling: Mark yes or no if door-to-door recycling is offered.

(b). County Households: Enter how many households in the county door-to-door recycling is provided for annually.

(c). Average Monthly Cost: Enter the average monthly cost per household for curbside recycling and yard waste pick-up.

Section 14. Total Amount of Recycling Materials (for recycling): For each item listed, enter the quantity of each recyclable collected by weight per year. If item not listed, enter these item(s) in the other column. Auto salvage yards and scrap yards shall report the number of tons of materials (metals, batteries, etc.) shipped off-site to be recycled, not parts sold for reuse.

All information submitted on this form will be subject to public disclosure to the extent provided by Kentucky law. Persons filing this form may make claims of confidentiality in accordance with 400 KAR 1:060.

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