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Home My WebLink AboutDSHW-2024-004635EPA Form 8700‐12, 8700‐13 A/B, 8700‐23 Page __ of __ United States Environmental ProtecƟon Agency RCRA SUBTITLE C SITE IDENTIFICATION FORM City, Town, or Village County State Country Zip Code LaƟtude Longitude 2.Site EPA ID Number Obtaining or updaƟng an EPA ID number for on‐going regulated acƟviƟes (Items 10‐17 below) that will conƟnue for a period of Ɵme. Submiƫng as a component of the Hazardous Waste Report for __________ (ReporƟng Year) NoƟfying that regulated acƟvity is no longer occurring at this Site Obtaining or updaƟng an EPA ID number for conducƟng Electronic Manifest Broker acƟviƟes Submiƫng a new or revised Part A (permit) Form  Site was a TSD facility, a reverse distributor, and/or generator of ≥ 1,000 kg of non‐acute hazardous waste, > 1 kg of acute hazardous waste, or > 100 kg of acute hazardous waste spill cleanup in one or more months of the reporƟng year (or State equivalent LQG regulaƟons) 1.Reason for SubmiƩal (Select only one.) 7.North American Industry ClassiﬁcaƟon System (NAICS) Code(s) for the Site (at least 5‐digit codes) 3.Site Name 4. Site LocaƟon Address 6.Site Land Type  Private County District Federal Tribal Municipal State Other A.(Primary)C. B. D. 5.Site Mailing Address Street Address State Country Zip Code City, Town, or Village  Same as LocaƟon Street Address Street Address  Use Lat/Long as Primary Address U T P 0 0 0 0 0 1 7 2 0 EPA Form 8700‐12, 8700‐13 A/B, 8700‐23 Page __ of __ First Name MI Last Name Title Street Address State Country Zip Code Email Phone Ext Fax City, Town, or Village 8. Site Contact InformaƟon Owner Type Private County District Federal Tribal Municipal State Other Street Address City, Town, or Village State Country Zip Code Email Phone Ext Fax Comments 9. Legal Owner and Operator of the Site A. Name of Site’s Legal Owner B. Name of Site’s Legal Operator EPA ID Number Full Name Date Became Operator (mm/dd/yyyy) Operator Type Private County District Federal Tribal Municipal State Other Street Address City, Town, or Village State Country Zip Code Email Phone Ext Fax Comments  Same as LocaƟon Address  Same as LocaƟon Address  Same as LocaƟon Address Full Name Date Became Owner (mm/dd/yyyy) EPA Form 8700‐12, 8700‐13 A/B, 8700‐23 Page __ of __ 10. Type of Regulated Waste AcƟvity (at your site) Mark “Yes” or “No” for all current acƟviƟes (as of the date submiƫng the form); complete any addiƟonal boxes as instructed. A. Hazardous Waste AcƟviƟes Y N 1. Generator of Hazardous Waste—If “Yes”, mark only one of the following—a, b, c a. LQG ‐Generates, in any calendar month, 1,000 kg/mo (2,200 lb/mo) or more of non‐acute hazardous waste (includes quanƟƟes imported by importer site); or ‐ Generates, in any calendar month, or accumulates at any Ɵme, more than 1 kg/mo (2.2 lb/mo) of acute hazardous waste; or ‐ Generates, in any calendar month or accumulates at any Ɵme, more than 100 kg/mo (220 lb/mo) of acute hazardous spill cleanup material. b. SQG 100 to 1,000 kg/mo (220‐2,200 lb/mo) of non‐acute hazardous waste and no more than 1 kg (2.2 lb) of acute hazardous waste and no more than 100 kg (220 lb) of any acute hazardous spill cleanup material. c. VSQG Less than or equal to 100 kg/mo (220 lb/mo) of non‐acute hazardous waste. Y N 2. Short‐Term Generator (generates from a short‐term or one‐Ɵme event and not from on‐going processes). If “Yes”, provide an explanaƟon in the Comments secƟon. Note: If “Yes”, you MUST indicate that you are a Generator of Hazardous Waste in Item 10.A.1 above. Y N 3. Treater, Storer or Disposer of Hazardous Waste—Note: Part B of a hazardous waste permit is required for these acƟviƟes. Y N 5 Recycler of Hazardous Waste a. Recycler who stores prior to recycling b. Recycler who does not store prior to recycling Y N 6. Exempt Boiler and/or Industrial Furnace—If “Yes”, mark all that apply. a. Small QuanƟty On‐site Burner ExempƟon b. SmelƟng, MelƟng, and Reﬁning Furnace ExempƟon Y N 4. Receives Hazardous Waste from Off‐site EPA ID Number B. Waste Codes for Federally Regulated Hazardous Wastes. Please list the waste codes of the Federal hazardous wastes handled at your site. List them in the order they are presented in the regulaƟons (e.g. D001, D003, F007, U112). Use an addiƟonal page if more spaces are needed. C. Waste Codes for State Regulated (non‐Federal) Hazardous Wastes. Please list the waste codes of the State hazardous wastes handled at your site. List them in the order they are presented in the regulaƟons. Use an addiƟonal page if more spaces are needed. EPA Form 8700‐12, 8700‐13 A/B, 8700‐23 Page __ of __ Y N 2. Underground InjecƟon Control Y N 4. Recognized Trader—If “Yes”, mark all that apply. a. Importer b. Exporter Y N 5. Importer/Exporter of Spent Lead‐Acid BaƩeries (SLABs) under 40 CFR 266 Subpart G—If “Yes”, mark all that apply. a. Importer b. Exporter EPA ID Number 11. AddiƟonal Regulated Waste AcƟviƟes (NOTE: Refer to your State regulaƟons to determine if a separate permit is required.) B. Universal Waste AcƟviƟes Y N 1. Large QuanƟty Handler of Universal Waste (you accumulate 5,000 kg or more) ‐ If “Yes” mark all that apply. Note: Refer to your State regulaƟons to determine what is regulated. a. BaƩeries b. PesƟcides c. Mercury containing equipment d. Lamps f. Other (specify) ______________________________________________ e. Aerosol Cans g. Other (specify) ______________________________________________ Y N 2. DesƟnaƟon Facility for Universal Waste Note: A hazardous waste permit may be required for this acƟvity. C. Used Oil AcƟviƟes Y N 1. Used Oil Transporter—If “Yes”, mark all that apply. a. Transporter b. Transfer Facility (at your site) Y N 2. Used Oil Processor and/or Re‐reﬁner—If “Yes”, mark all that apply. a. Processor b. Re‐reﬁner Y N 3. Off‐SpeciﬁcaƟon Used Oil Burner Y N 4. Used Oil Fuel Marketer—If “Yes”, mark all that apply. a. Marketer Who Directs Shipment of Off‐SpeciﬁcaƟon Used Oil to Off‐SpeciﬁcaƟon Used Oil Burner b. Marketer Who First Claims the Used Oil Meets the SpeciﬁcaƟons A. Other Waste AcƟviƟes Y N 3. United States Importer of Hazardous Waste Y N 1. Transporter of Hazardous Waste—If “Yes”, mark all that apply. a. Transporter b. Transfer Facility (at your site) EPA Form 8700‐12, 8700‐13 A/B, 8700‐23 Page __ of __ 12. Eligible Academic EnƟƟes with Laboratories—NoƟﬁcaƟon for opƟng into or withdrawing from managing laboratory hazardous wastes pursuant to 40 CFR Part 262, Subpart K. Y N A. OpƟng into or currently operaƟng under 40 CFR Part 262, Subpart K for the management of hazardous wastes in laboratories— If “Yes”, mark all that apply. Note: See the item‐by‐item instrucƟons for deﬁni‐ Ɵons of types of eligible academic enƟƟes. 1. College or University 2. Teaching Hospital that is owned by or has a formal wriƩen affiliaƟon with a college or university 3. Non‐proﬁt InsƟtute that is owned by or has a formal wriƩen affiliaƟon with a college or university EPA ID Number Y N Are you an LQG noƟfying of consolidaƟng VSQG Hazardous Waste Under the Control of the Same Person pursuant to 40 CFR 262.17(f)? If “Yes”, you must ﬁll out the Addendum for LQG ConsolidaƟon of VSQG hazardous waste. Y N LQG Site Closure of a Central AccumulaƟon Area (CAA) or EnƟre Facility. A. Central AccumulaƟon Area (CAA) or EnƟre Facility B. Expected closure date: ____________ mm/dd/yyyy C. RequesƟng new closure date: ____________ mm/dd/yyyy D. Date closed : ____________ mm/dd/yyyy 1. In compliance with the closure performance standards 40 CFR 262.17(a)(8) 2. Not in compliance with the closure performance standards 40 CFR 262.17(a)(8) 14. LQG ConsolidaƟon of VSQG Hazardous Waste 15. NoƟﬁcaƟon of LQG Site Closure for a Central AccumulaƟon Area (CAA) (opƟonal) OR EnƟre Facility (required) Y N Are you an SQG or VSQG generaƟng hazardous waste from a planned or unplanned episodic event, lasƟng no more than 60 days, that moves you to a higher generator category. If “Yes”, you must ﬁll out the Addendum for Episodic Generator. 13. Episodic GeneraƟon D. PharmaceuƟcal AcƟviƟes Y N 1. OperaƟng under 40 CFR Part 266, Subpart P for the management of hazardous waste pharmaceuƟ‐ cals—if “Yes”, mark only one. Note: See the item‐by‐item instrucƟons for deﬁniƟons of healthcare facility and reverse distributor. a. Healthcare Facility b. Reverse Distributor Y N 2. Withdrawing from operaƟng under 40 CFR Part 266, Subpart P for the management of hazardous waste pharmaceuƟcals. Note: You may only withdraw if you are a healthcare facility that is a VSQG for all of your hazardous waste, including hazardous waste pharmaceuƟcals. Y N B. Withdrawing from 40 CFR Part 262, Subpart K for the management of hazardous wastes in laboratories. EPA Form 8700‐12, 8700‐13 A/B, 8700‐23 Page __ of __ EPA ID Number 18. Comments (include item number for each comment) 19. CerƟﬁcaƟon I cerƟfy under penalty of law that this document and all aƩachments were prepared under my direcƟon or su‐ pervision in accordance with a system designed to assure that qualiﬁed personnel properly gather and evaluate the informaƟon submiƩed. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gath‐ ering the informaƟon, the informaƟon submiƩed is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are signiﬁcant penalƟes for submiƫng false informaƟon, including the possibility of ﬁnes and imprisonment for knowing violaƟons. Note: For the RCRA Hazardous Waste Part A permit ApplicaƟon, all owners and operators must sign (see 40 CFR 270.10(b) and 270.11). Signature of legal owner, operator or authorized representaƟve Date (mm/dd/yyyy) Printed Name (First, Middle IniƟal Last) Title Email Signature of legal owner, operator or authorized representaƟve Date (mm/dd/yyyy) Printed Name (First, Middle IniƟal Last) Title Email 17. Electronic Manifest Broker Y N Are you noƟfying as a person, as deﬁned in 40 CFR 260.10, elecƟng to use the EPA electronic manifest sys‐ tem to obtain, complete, and transmit an electronic manifest under a contractual relaƟonship with a haz‐ ardous waste generator? 16. NoƟﬁcaƟon of Hazardous Secondary Material (HSM) AcƟvity Y N Are you noƟfying under 40 CFR 260.42 that you will begin managing, are managing, or will stop managing hazardous secondary material under 40 CFR 260.30, 40 CFR 261.4(a)(23), (24), (25), or (27)? If “Yes”, you must ﬁll out the Addendum to the Site IdenƟﬁcaƟon Form for Managing Hazardous Secondary Material.