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Please print or t:ype with ELITE type (12 char per inch) in the unshaded areas only Agproved, OMB No. 205&Wg Expires lUSt/9g
GSA A/o. 0246-EPA-OT
EPA Form 87m-12 (Rev. 10109/96)-1o12
lD - For Official Use Only
Vlll. Type of Regulated Waste Actlvlty (Mark'X' tn tho appropriate bores. Reler to tnstructlong )
A. Hazardous Waste Activity B. Used Oil Recycling Activities
Generator (See lnstructions)
a. Greater than lt)filkg/mo (2,2fi) lbs.)
b. 100 to 1000 kg/mo (220-2,200 lbs.)
c. Less than 100 kg/mo (22O lbs)
Transporter (lndlcate Mode ln boxes 1-
5 below)
n a. For own waste only
n b. For commorclal purposes
Mode ol Transportatlon
D 1. Alr
n 2. Rait
U 3. Hlghway
n 4. water
[ 5. othet - spoclly
Treater, Storer, Dlsposer (at
lnstaltation) Note: A permit is
required lor this activity, see
lnstructlons.
Hazardous Waste Fuel
a. Generator Marketlng to Burner
b. Other Marketers
c. Boiler andor lndustla! Furnace
n 1. Smelter Deferral
E 2. Smatl Quantity Exemption
lndicate Type of Combustlon-
Devlce(s)
tr 1. Utility Boiter
U 2. lndustrial Boiler
t] 3. lndustrlat Furnace
Underground Infection Control
tr1.xnr
2.4.
E
n
1. Used Oil Recycling Marketer
I a. Marketer Directs Shipment of Used
Oil to Off-Specification Burner
n b. Marketer Who First Claims the
Used Oil Meets the Speciflcatlons2. Used Oll Burner - lndlcate Type(s)
of Combustlon Devlcefl a. Utillty Boitern b. tnduitrlat Boiler
f, c. tndustrial Furnace3. Used Olt Transporter - tndicate' Type(s) ol Combustion Device(s)
a. Transporter
b. Transfer Facllity4. Used Oll Processor/R+refiosr -
fI a. Process
tr b. Re-refine
l.lonltablo 2 Corrorlvc 3. Reactlve(ooot) poe) pms)
lX. Descrlptlon bt Regulated Wastes (Useadditrbnarsheets irnecesgary, ' 'E
A. Characteristics of Nonlisted Hazardous Wastes. (Mark'X'in the boxes corresponding to the characteristics of
nonlisted hazardous wastes your lnstallation handles; See 40 CFR Parts 261.20 - 261.24)
4.Torlclty (Llst speclflc EPA hazardour wagte numffs) for the Toxlclty characterlstlcCharacterletlc contamlnant(r))utrIEtrrrlrr]llrr]-llt
B. Listed Hazardous Wastes. (See 40 CFR 261.31 - 33; See instructions il you need to list more lhan 12 waste codes.)
C. Other Wasles. (Stata or other wastes requlring a handler.to have an l.D. number; See instructions.)
I certify undor ponelly ol law that thls document tnd.ll att6chment3 wero prepared under my dir€ction or supervision in accordance wlth
a system derigned lo assurs thst qualilled personnel properly gathet and evaluate the lnlormation submitted. Basod on my inquiry ol lhe
person or persons who manage the 3y3tom, or tho3o persons directty responsible tor gathering the information, the information submitted
is, to the best ol my knowledgb and belief, true, accurate, bnd complele. I am aware that there ire signilicant penalties lor submitting lalse
information, including the possibility ol fine and imprisonment lor knowing violations.
-Nemn and Official Title (Type or print)
#rA*J t 6":**. {t *;r ru,*, "
Date Signed
/o/r D7
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Ch4*. 1e. rl%e;-.q{'r.t. S+q{.^S
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Pl€ase print or type with ELITE type 1r, f.,"r. per inch) in lhe unshaded areas only O
,
Form Approved, OMB No. 2050-0028'Exgtres lU3l/99
GSA No. C2J6-EPA-OT
mm
EPA Form 8700-12 (Hev. 10109/96)-2ot2