Form Sw Fsd 1 – Fill Out and Use This PDF

July 1, _____ thru June 30, _______

Page______ of ______

LOUISIANA DEPARTMENT OF ENVIRONMENTAL QUALITY

INDUSTRIAL SOLID WASTE GENERATOR ANNUAL REPORT

(To Complete Please Refer to the Detailed Instructions)

1.Site Identification No. ___________________________________________

2.Agency Interest Number____________________________

3.Name of Generator __________________________________________________________________________

4.Mailing Address____________________________________________ Parish_________________________________

Physical Address

Latitude

°-

’-

” Lo gitude

°-

’-

”

Datu ir le o e NAD8 WGS8

5.Contact _________________________________________________ Telephone (_______) ______________________

6.SUMMARY OF INDUSTRIAL SOLID WASTE GENERATED THIS YEAR:

(If additional sheets are required, please provide your identification number and the date on each sheet)

	Total Amount
	Generated
7.	CERTIFICATION: I certify under penalty of law that I have personally examined and am familiar with the information submitted in

this and all attached documents, and based on my inquiry of those individuals immediately responsible for obtaining the information; I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

Signature__________________________________________________________Date __________________________________

Name and Title___________________________________________________________________________________________

Print or type the name and title of the person signing the form

This report is to be submitted to the Office of Environmental Services (address below) no later than August 1 following the end of each reporting year. Failure to submit this report on or before August 1 following the end of each reporting year is a violation of LAC 33:VII.Subpart 1, and may result in enforcement action by the Department under the authority granted by the Louisiana Environmental Quality Act (the Act), La. R.S. 30:2001, et seq., and particularly by La. R.S. 30:2025(C), 30:2050.2 and 30:2050.3(B). The Department reserves the right to seek civil penalties in any manner allowed by law for each violation.

Waste Permits Division

Attn: SW Reports

P. O. Box 4313

Baton Rouge, LA 70821-4313

SW-FSD-1

11/2011

July 1, _____ thru June 30, _______

Page______ of ______

INDUSTRIAL SOLID WASTE GENERATOR ANNUAL REPORT

Detailed instructions

The Solid Waste Generator Annual Report covers generation of waste for the period beginning July 1 and ending June 30 of each year. This is to be submitted by August 1 following the end of each year. Questions regarding the form may be directed to the Waste Permits Division at 225-219-3388.

1.Identification number: Indicate the facility identification number that has been assigned to the generator by the Administrative Authority. Also, enter the year in which the report applies.

2.Agency Interest Number: Indicate the facility identification number that has been assigned to the generator by the Administrative Authority.

3.Name of Generator: Enter the name of the entity reporting the industrial solid waste generated this year.

4.Mailing Address: Enter the mailing address for the facility, the parish location, the latitude (in degrees, minutes, seconds), the longitude (in degrees, minutes, seconds), and the datum used to obtain the latitude and longitude.

5.Contact: Enter the name of the person knowledgeable about the information submitted on the form and his/her telephone number.

6.Summary of Industrial Solid Waste Generated this Year: For each individual solid waste generated, list the Industrial waste code number (the number assigned to the waste by the Office of Environmental Services, Waste Permits Division), indicate the total amount of waste generated (in wet-weight tons ONLY), enter the identification number for the collector/transporter and the disposer of the waste.

Add up the amounts reported and enter the total in the Total Amount Generated box.

If additional sheets are required, please put your identification number and the date on each sheet. Also, add up the amounts reported on all pages and put the total in the Total Amount Generated box on the FIRST PAGE ONLY.

7. Certifi atio y sig ature: The legally authorized represe tative of the site’s operatio should sig

the form. Print or type the date, the name and the title of the person signing the form.

SW-FSD-1

11/2011