County of Los Angeles Department of Public Works

County of Los Angeles Department of Public Works
Plastic and Paper Carryout Bag Ordinance
LA County Code Chapter 12.85
Quarterly Report Form
This form must be completed and signed by a responsible agent or officer of the store location, and must be submitted no later
than 30 days after the end of each quarter.
Store Name:
Date:
Store Address:
Store ID:
Phone Number:
Email Address:
Reporting Quarter:
(Check one)
Q1 (January 1 - March 31)
Q2 (April 1 - June 30)
Q3 (July 1 - September 30)
Q4 (October 1 - December 31)
Year:
Total number of recyclable paper carryout bags provided:
(including those provided free of charge to EBT, WIC, and/or SNAP customers)
Total amount of monies collected for providing recyclable paper carryout bags: $
(actual monies collected for providing paper carryout bags are to be retained by the store)
Voluntary efforts undertaken to promote the use of reusable bags by customers in the prior quarter:
You may attach related printed outreach material, photos, or videos (or internet web links) for County use in promoting store efforts.
Provided reminders to customers about bringing their reusable bags with them.
Provided incentives to encourage reusable bags.
Prominently displayed reusable bags in the store.
Displayed flyers, posters, or banners to make customers aware of the benefits of using reusable carryout bags.
Undertook efforts to make the public aware of the impacts of littered bags on the environment.
Other:
"I confirm that the information provided is accurate and complete."
Signature
Signature
Store Location Responsible Agent/Officer Name (Print)
Store Corporate Representative Name (Print)
ENVIRONMENTAL PROGRAMS DIVISION | P.O. Box 1460, Alhambra, CA 91802‐1460 | PHONE: (626) 458‐3538; FAX: (626) 979‐5389
07/14