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2. This form is to be completed by commercial, municipal or institutional establishments in PA

   Commercial Establishment: An establishment engaged in non-manufacturing or non-processing business, including, but not limited to, stores, markets, office buildings, medical offices, restaurants, shopping centers and theaters.

   Municipal Establishment: An establishment engaged in government work including, but not limited to, offices of the federal government, state government, cities, boroughs, incorporated towns, townships, counties and authorities.

   Institutional Establishment: An establishment engaged in service including, but not limited to, hospitals, nursing homes, orphanages, schools and universities.

   The information on this form will be used by the municipality where you are located to gauge your compliance with their recycling ordinance (if they have one) and to complete a recycling performance grant. The materials listed on the first page may be required by local ordinance to be recycled and, with the exception of the organics, can be used for the municipal recycling performance grant. The materials listed on the second page are common materials recycled, but they are not usually required to be recycled by local ordinance and cannot be used for the municipal recycling performance grant.

   The report is due to our office on or before February 8th.

4. Please use the following checklist to complete form FM-11:

   1. Insert the current reporting year (upper right-hand corner of form).
   2. Insert the county and municipality where your establishment is located
   3. Complete the information about your business (For instance: Manufacturing, Office/Administrative Services, Wholesale/Retail, Institution, Government, Medical or Other - Please explain)
   4. Check which best describes how recyclables are handled within your establishment ( Source Separated, Commingled or Single Stream)
   5. Check which best describes how your recyclable materials are collected
   6. Place a check beside the materials your establishment recycles
   7. Submit to the municipality where you are located
6. You must attach a legible weight ticket from your recycler for any materials recycled on page 1
   **ENTER the GROSS WEIGHT of all material. DO NOT subtract processing residue before entering your tonnages on this form. Processing residue is material that is collected and weighed with recyclables, but is disposed rather than recycled. PA DEP has a formula it will use to subtract processing residue.
   
   DO NOT REPORT PROCESSING RESIDUES ON THIS FORM.
   
   If you deliver your materials commingled or single stream, please check the appropriate boxes to note the recyclable materials in the mix, but only enter the tonnage beside commingled or single stream. Do not estimate tonnages of each individual recyclable material in the commingled or single stream mix.
8. Use this conversion chart as necessary
   Antifreeze: 7.2 lbs per gallon
   
   Battery – Lead Acid:
   Car = 17.8 lbs
   Truck = 48.7 lbs
   Motorcycle = 8.7 lbs
   
   Rubber Tires:
   Car = 21 lbs
   Truck = 70 lbs
   
   Used Oil: 7.2 lbs per gallon
   
   Oil Filters: 1.2 lbs each
   
   Glass – Whole Bottle: 1 ton = 2 yds3
   
   Newsprint – Loose: 1 ton = 3 yds3
   
   Corrugated Cardboard: 2.5’ x 4’ x 5’ bale = 1100 lbs
   
   Plastic Soda Bottles
   Whole, Loose: 30 lbs = 1 yd3
   
   Plastic Film: 2.5’ x 4’ x 5’ bale = 1500 lbs
   
   Solid & Liquid Fats: 55 gallon drum = 412 lbs
   
   White Goods
   Freezers: 1 = 250 lbs
   Refrigerators: 1 = 250 lbs
   Other Appliances: 1 = 150 lbs
   
   Yard Waste
   Leaves: 4 yd3 = 1 ton
   Grass Clippings: 2 yd3 = 1 ton
   Wood Chips: 1 yd3 = 500 lbs
12. Form FM-11. REV. 10/27/20
13. ACT 101 RECYCLING COMPLIANCE REPORT
    For Commercial, Municipal, Institutional Facilities
15. BERKS COUNTY
16. MUHLENBERG TOWNSHIP
18. Name of Establishment
19. Email Address
21. Address
23. City
24. Zip Code
26. Phone Number
27. Fax Number
29. Primary Business Function
31. How does your establishment handle recyclable materials?

    1. Source-separated
    2. Commingled
    3. Single Stream
33. If you choose one of the three options below and provided the name of collector, submit now.
35. How are your recyclable materials collected?
    -- Select One --Collected by recycling facility or brokerCollected by private haulerCollected by confidential document destruction company
37. Name or Location
    Please provide name or location for the option above
41. If you choose one of the three options below and provided the name of collector, complete form below.
43. Establishment delivers materials
    -- Select One --Drop-off siteCurbside programRecycling facility
45. Name or Location
    Please provide name or location for the option above
49. 1. CHECK the box in front of each pre-consumer* material that your establishment recycled.
51. 2. Enter the weight in tons and attach a legible weight ticket from your recycler. Enter the GROSS WEIGHT**. DO NOT subtract any processing residue.
53. 3. CHECK the box in front of each pre-consumer material recycled at your establishment.
55. 4. If you market the recyclables yourself, enter the weight (in tons) of material recycled.
57. 5. If you use a commingled or single stream collection system, check the boxes beside each material in the mix.
59. Material Type

    1. Single Stream

    (all recyclables, including fiber, collected together)
60. Weight
62. Material Type

    1. Commingled

    (two or more materials collected together, fiber separate)
63. Weight
65. Glass Bottles and Jars

    1. Glass: Clear
    2. Glass: Mixed
    3. Glass: Green
    4. Glass: Brown
    5. Glass: Plate
    6. Glass: Other
66. Weight
68. Paper

    1. Paper: Cardboard
    2. Paper: Brown Bags & Sacks
    3. Paper: Gabled / Aseptic Cartons
    4. Paper: Magazines & Catalogs
    5. Paper: Newsprint / Newspaper
    6. Paper: Mixed / Other Paper Grades (junk mail, paperboard, etc.)
    7. Paper: Office Paper (all high grades)
    8. Paper: Phone Books
    9. Drum: Fiber
69. Weight
71. Plastics

    1. Plastic: PET
    2. Plastic: HDPE
    3. Plastic: PVC
    4. Plastic: LDPE
    5. Plastic: PP
    6. Plastic: PS
    7. Plastic: MIXED / OTHER
    8. Plastic: FILM
    9. Plastic: DRUM (high molecular HDPE)
    10. Plastic: DRUM (mixed bulky rigid)
72. Weight
74. Metals

    1. Aluminum Cans
    2. Steel / Bimetallic / Tin Cans
    3. Mixed Cans
    4. Aluminum Scrap
    5. Ferrous Metals
    6. Non-Ferrous Metals
    7. Copper
    8. Brass
    9. Lead
    10. Stainless Steel
    11. Nickel
75. Weight
77. **Enter GROSS WEIGHT of all material. DO NOT subtract any processing residue as PA DEP has a formula it will apply
79. Household / Commercial Hazardous Waste

    1. Antifreeze
    2. Batteries: Lead Acid
    3. Batteries: Other
    4. E-Waste (includes TV)
    5. Fluorescent Tubes / CFLs
    6. Used Oil
    7. Oil Filters
    8. Other Commercial HW (paints, varnish, pesticides, etc.)
    9. Other Household HW (paints, varnish, pesticides, etc.)
80. Weight
82. Other Recyclables

    1. Asphalt
    2. Rubber Tires
    3. Construction & Demolition
    4. Clothing / Textiles
    5. Furniture & Furnishings
    6. Mattresses
    7. Misc. / Other Consumer Items
83. Weight
85. Organics

    1. Source Separated Foods
    2. Wood Waste
    3. Yard & Leaf Waste
86. Weight
88. I certify, to the best of my knowledge, that the information on this form is complete and accurate. I further authorize the Municipality to aggregate this report for DEP reporting purposes. If a legible weight ticket is attached, this report may also be used for DEP grant purposes.
90. Upload weight slips, if required.
    If you have more than one file, you can e-mail them directly to Jim Bobeck at jbobeck@muhlenbergtwp.com
92. Authorized Representative
94. Title
96. Electronic Signature
98. Date
Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit Submit and Print

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