EPA's WasteWise Program (State)

Assessment
Form

OMB No. 2050-0139
Expiration Date: July 31, 2007

Please take care when reporting, measurements of your activities are important. A sample Annual Assessment Form and reporting
instructions are available on the WasteWise Web site in the “Publications Directory” . Completed forms can
be submitted by email . If you have questions, call (800) EPA-WISE (372-9473) or email .

Section I - Participant Information
Organization Name: _______________________________________________________________________________________ Phone:_______________________________________________
Principal Contact: __________________________________________________________________________________________ Email:________________________________________________
Facilities Included in Report:_ _______________________________________________________________________________ Number of Total Employees:___________________________

Section II - Current Waste Reduction Activities
This Report Covers Data Measured From:_____________________________________ (Date)   To: __________________________________________________________ (Date)
Total Amount of Municipal Solid Waste Disposed of During Reporting Period: ______________________________________________________________ (Pounds or Tons*)
This Information Is (please check one):

o Baseline Data

o Annual Data

In the chart below, provide your waste prevention and recycling data. If this is your first time reporting data to WasteWise, you are reporting baseline data. If you have
previously submitted data to WasteWise, provide data for this reporting year. Photocopy this page if you need more space.
Waste Prevention
Product/Material

Description of Waste Prevention Activity

Amount Prevented
(Pounds or Tons*)

Goals for Upcoming Year

Amount Recycled
(Pounds or Tons*)

Goals for Upcoming Year

Recycling
Product/Material

Description of Recycling Activity

* Please note if data is reported as pounds or tons.

Section III - Cost Savings/Revenue
In the lines below, please provide information on the revenues/savings generated from the waste reduction activities listed in Section II.
Total Waste Prevention Revenue: $____________________________________ Total Recycling Revenue: $ _ ___________________________________
Total Avoided Purchasing
Total Avoided Disposal Costs Due to
Costs Due to Waste Prevention: $______________________________________ Recycling and Waste Prevention: $ _____________________________

Section IV - Buy/Manufacture Recycled Products
In the chart below, please provide information on products containing recycled content that you have purchased or manufactured.
Buy/Manufacture Recycled Products

Product/Material

Current Recycled
Content
Percent (%)

Previous Recycled
Content
Percent (%)

Current Units (Purchased or Manufactured)

Section V - Comments
Please attach any additional information you would like to share about your activities (e.g., external promotion of WasteWise, employee education, etc.) or comments
about the WasteWise program. With permission from individual organizations, EPA will share successes with others.

Three options for submitting your Annual Assessment Form:
1 Email to:
2M
 ail to:
EPA WasteWise
c/o ICF International
9300 Lee Highway
Fairfax, VA 22031

3 F ax to: WasteWise c/o ICF International:
(703) 934-3183

Signature of Principal Contact:_________________________________________________________________________________________________ Date:______________________________
Print Name: __________________________________________________________________________________________Title:_______________________________________________________