1. APPLICATION FOR REIMBURSEMENT FOR A COUNTY RECYCLING COORDINATOR
      2. DEPARTMENT USE ONLY
      3. Supplier Invoice #:
      4. VENDOR ID #: Invoice Date:
      5. SAP FUND GEN. LEDGER COST CENTER INT. ORDER
      6. 20089 000 6600400 3522509000 35250000
      7. TOTAL AMOUNT APPROVED FOR PAYMENT: $

2500-FM-BWM0213 Rev. 9/2011
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
- 1 -
APPLICATION FOR REIMBURSEMENT
FOR A COUNTY RECYCLING COORDINATOR
THE PENNSYLVANIA MUNICIPAL WASTE PLANNING, RECYCLING AND WASTE REDUCTION ACT,
ACT 101 OF 1988 (P.L. 556), Section 903
Please read all instructions before completing. The Department must receive this application by the announced deadline for all duties performed from
January 1 through December 31 for the previous calendar year.
SECTION A
1. COUNTY:
2. OFFICIAL BUSINESS ADDRESS:
Number - Box
Street
Municipality
P
A
State
Zip Code
3. FEDERAL I.D. #
4. FOR CALENDAR YEAR
:
20
DEPARTMENT USE ONLY
Supplier Invoice #:
VENDOR ID #:
Invoice Date:
SAP FUND
GEN. LEDGER
COST CENTER
INT. ORDER
20089
000
6600400
3522509000
35250000
TOTAL AMOUNT APPROVED FOR PAYMENT:
$
Signature
Date
All supporting documentation for the application is on file in the County Office.

2500-FM-BWM0213 Rev. 9/2011
- 2 -
SECTION B - County Recycling Coordinator Job Description
(Explain responsibilities and duties)

2500-FM-BWM0213 Rev. 9/2011
- 3 -
SECTION C - County Contact
County Contact Person (Name and Title)
Telephone
(
)
-
SECTION D - County Recycling Coordinator Identification
Name
Address
City
State
PA
Zip
Telephone:
(
)
-
E-mail Address:
Fax #:
(
)
-
Web Address:
Certification:
Certified Recycling Professional
Sr. Certified Recycling Professional
None
Specialty:
Composting
Processing
Enforcement
Collection
Management
Processing
Education
Composting Operator
Operator
SECTION E - County Recycling Coordinator Time/Employment Status
Employment Status:
County Employee
Independent Contractor
Solid Waste Authority
Hours Paid Per Week:
Normal Days Worked in Week:
through
Number Recycling Hours Paid Per Year
Normal Hours Worked in Day:
to
Weeks Worked Per Year:
Pay Rate:
Per Hour:
Per Year:
Dates of Employment: from
to
SECTION F - Summary of County Recycling Activity from January 1 through December 31 of preceding year
Recycling Programs in County
Number of Municipalities
with Curbside Recycling
Number of Municipalities
with Drop-Off Recycling
Number of Municipalities
without Recycling
Programs
1. Municipalities > 10,000 population.....................
2. Municipalities 5,000-10,000 population .............
3. All others............................................................
TOTAL ......................................................
SECTION G
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
I,
,
, state that I am an Official of the
Name
Title
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
official function, is an action punishable by law.
APPLICATION SUBMITTED THIS
DAY OF
, 20
.
I hereby accept the terms described above.

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