160-123 Main Street (Box 50) Winnipeg, Manitoba R3C 1A5 PHONE: (204) 945-3268 FAX: (204) 945-1211

WASTE REDUCTION AND RECYCLING SUPPORT (WRARS) PROGRAM LANDFILL LEVY REMITTANCE FORM

FORM C: LANDFILLS USING THE PER CAPITA WRARS REGISTRATION NUMBER: ______WASTE FACTOR (Per Capita Waste)

CONTACT INFORMATION Landfill(s) Owner: Authorized Contact: Title: Address: Town/City: Postal Code: Phone Number: Fax Number: Email Address: Web Site:

REPORTING PERIOD (YEAR______)

 January 1 to June 30  July 1 to December 31

For each disposal facility owned, please identify the facility class and the source and amount of waste disposed in the landfill for the appropriate reporting period. If applicable, disposal amounts must include the amount of waste burned on site and at Waste Transfer Stations. Population Total Weight (T) (Population Served x Per WRARS Levy Landfill Name Served by Capita Waste Factor of (Total Weight x $10) Landfill 0.33 Tonnes)

Class:  2  3

Class:  2  3

Class:  2  3 $ TOTAL Total Population Total Weight (T) Total WRARS Levy Remitted Please make cheques payable to: Green Manitoba Please send the cheque together with the completed form.

Page 1 of 2 160-123 Main Street (Box 50) Winnipeg, Manitoba R3C 1A5 PHONE: (204) 945-3268 FAX: (204) 945-1211

Approximate % of Waste Disposed by Source Industrial, Commercial & Residential Construction & Demolition Institutional

Please list all Municipalities using the landfill(s), including populations served: 1. 2. 3. 4.

Please list other landfills used by the municipality, including the population served by each landfill: 1. 2. 3. 4.

DECLARATION The WRARS Levy is equal to $10 times the total tonnes of waste disposed at a Class 1, Class 2 or Class 3 landfill site and must be paid to Green Manitoba for each six (6 ) month period, as set out in the Waste Reduction and Recycling Support (WRARS) Program Registration Guide. The conditions of this agreement include: 1. Records must be maintained on file for a five (5) year period. 2. Records will be provided to an agent of Green Manitoba upon request. 3. All reported landfill data may be subject to an independent audit on a periodic basis.

The landfill owner understands the requirements for the WRARS Program and agrees to cooperate with all WRARS policies and procedures.

Authorized Contact Signature Date

Send Completed Form to: WRARS Program c/o Green Manitoba 160-123 Main Street (Box 50) Winnipeg, MB R3C 1A5 Fax: 204-945-1211 Phone: 204-945-7042 E-mail: [email protected]

For Green Manitoba Use Only Date Processed: WRARS Registration Number: Approved By:

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