DSHW-2024-004459

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Annual Report Instructions

Used Oil Annual Report

Note: You (permittee) can use this form to prepare and submit annual reports for more than one permit (e.g., used oil
transporter, transfer facility, processor, off-spec burner). Simply, fill in each option on the first page for all the permits
you have been approved for to operate in Utah, then complete and submit all applicable pages for each permit being
reported. If you only have one permit, then complete the top option for the type of permit being reported and submit all
applicable pages in the report for that permit.

Permit Information

Type of Permit (This data field is required)
Select from the dropdown menu. There are four types of permits you can select from (e.g., used oil transporter, transfer
facility, processor, off-spec burner). There is room for three types of permits on this form and their corresponding
information. If you are only reporting for one type of permit, you will need to select the “N/A” option for the other two
selections.

Used Oil Permit Number (This data field is required)
Write the permit number that was given to you (e.g., UOR-0123). You can get this information from the letter of
approval signed by the director.

Used Oil Permittee Full Legal Name (This data field is required)
Write the full legal name of the individual person or legal business entity as it appears on your permit which should be
the same name as your business was registered with the Utah Department of Commerce, or in the state of origin. No
DBA’s. If you have a DBA, you must write the full legal name, plus the DBA name (e.g., Business Name DBA Business).

Permittee EPA ID Number (This data field is required)
Write the EPA identification number for your business. This is for the address where the used oil activities are
conducted from. This number should follow the proper format (For example UTR123456789).

Permitted Facility Principal Place of Business (street, city, state, and zip code) (This data field is required)
Write the physical address of the permitted facility which may be different from the business address and mailing
address. Write the street address, city, state, and zip code number (two lines).

Mailing Address (street, city, state, and zip code)
Write the mailing address of the business if different than the permitted facility principal place of business. Write the
street address, city, state, and zip code number (two lines). The Division must be able to use this address to mail
correspondence to the business.

Main Telephone Number
Write the main phone number (Area code + 7 digits). This must be a working phone number the Division can use to
reach the business.

Annual Report Contact Name (This data field is required)
Write the full name of the person responsible for this annual report. This contact may not necessarily be the person that
prepares the annual report. This contact must be able to not only answer questions about the report, but also be able
to make and resubmit corrections to the annual report, or direct someone to do so.

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Annual Report Contact Telephone Number (This data field is required)
Write the annual report contact (see annual report contact name above) phone number (Area code + 7 digits). This
must be a working phone number the Division can use to reach the contact person.

Annual Report Contact Email Address (This data field is required)
Write the annual report contact (see annual report contact name above) email address (Area code + 7 digits). This must
be a working email address the Division can use to reach the contact person.

Note: Some fields on this form are required. Each selection must be completed for each type of permit being reported
on this form. If you are only reporting for one type of permit, you will need to select the “N/A” option for required fields
for the other two selections.

Certification

Name of Authorized Person Signing Annual Report (printed) (This data field is required)
Write the name of the person certifying the information in the annual report is true and correct. This may be the owner,
manager, or person preparing and submitting the report or any other authorized person.

Title (This data field is required)
Write the title of the person certifying the information in the annual report is true and correct.

Signature (This data field is required)
The signature of the person certifying the information in the annual report is true and correct. This can be done
electronically or by hand.

Date (This data field is required)
Write the date the annual report was signed by the person certifying the information in the annual report is true and
correct.

Note: You may email the annual report to [e-mail]. You may also mail in the annual report to the State
of Utah, Department of Environmental Quality, Division of Waste Management and Radiation Control, P.O. Box 144880
in Salt Lake City, UT 84114-4880. Or you may submit it in person to the State of Utah, Department of Environmental
Quality, Division of Waste Management and Radiation Control located at 195 North 1950 West, Multi-Agency State
Office Building, 2nd Floor in Salt Lake City, Utah 84116.

For questions please call [phone] and ask for the Used Oil section.

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Used Oil Transporter
Annual Report

Note: Use this portion of the report if you are reporting used oil activities for your used oil transporter permit.

Used Oil Collections and Deliveries Summary

A. Enter the volume in gallons of used oil imported into Utah. Please use the attachment “Collections and Deliveries,
Inventory Balance Explanation” provided with the form to itemize the individual totals imported to each facility in Utah.

B. Enter the volume in gallons of used oil collected in Utah. Please use the attachment “Collections and Deliveries,
Inventory Balance Explanation” provided with the form to itemize the individual totals collected at each facility in Utah.

I. Add lines A and B and enter the total in gallons. This is the total volume in gallons of used oil collections.

C. Enter the volume in gallons of used oil delivered in Utah. Please use the attachment “Collections and Deliveries,
Inventory Balance Explanation” provided with the form to itemize the individual totals delivered to each facility in Utah.

D. Enter the volume in gallons of used oil delivered outside Utah. Please use the attachment “Collections and
Deliveries, Inventory Balance Explanation” provided with the form to itemize the individual totals delivered at each
facility outside Utah.

II. Add lines B and C and enter the total in gallons. This is the total volume in gallons of used oil deliveries.

E. Collection and Deliveries Comparison: If Used Oil Collections total (from I) and Used Oil Deliveries total (from II) are
different, please provide explanation using the attachment “Collections and Deliveries, Inventory Balance Explanation”
provided with the form.

Used Oil Filter Handling

Volume Estimates (Conversion from drums to number of filters)
• One 55-gallon drum of crushed used oil filters = ~400 used oil filters
• One 55-gallons drum of uncrushed used oil filters = ~250 used oil filters
• One ton of drained used oil filters = ~2,350 used oil filters

F. Using the volume estimates, enter an estimate number of used oil filters collected from generators or facilities in
Utah.

G. Using the volume estimates, enter an estimate number of used oil filters collected from generators or facilities
outside Utah and transported to a facility in Utah (imported).

H.1. Enter an estimated number of filters transferred to another permitted used oil facility in and outside Utah,
respectively.

H.2. Enter an estimated number of filters transferred directly to a waste-to-energy facility in and outside Utah,
respectively.

H.3. Enter an estimated number of filters transferred directly to a metal foundry for recycling in and outside Utah,
respectively.

H.4. Enter an estimated number of filters disposed to a landfill in and outside Utah, respectively.

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H.5. Enter an estimated number of filters disposed using other disposal methods.

Total. Add lines H.1 through H.5 for each column (In Utah, Outside Utah). This will be your estimated number of
filters disposed in and outside Utah, respectively.

I. Enter the name(s) of the facility(ies) where filters were transferred, and describe how the filters were managed (e.g.,
crushed and recycled, shredded, and so on) using the attachment “Used Oil Filter Handling” provided with the form.

Submit the Following Financial Assurance Documents

Please submit the following financial assurance documents with this report:
• A current General Liability Insurance (ACORD) form or equivalent showing General Liability Coverage (available
from insurance broker).
• A current Environmental Pollution Liability Insurance for Third-Party Damages showing Third-Party Damages
Coverage (Used Oil Financial Form 17.6).

Forms are available in our official website under Financial Forms (R315-15-10 and R315-15-12) at
https://deq.utah.gov/waste-management-and-radiation-control/forms-division-of-waste-management-and-radiation-
control#used-oil.

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Used Oil Transfer Facility
Annual Report

Note: Use this portion of the report if you are reporting used oil activities for your used oil transfer facility permit.

Used Oil Inventory

A. Enter the beginning inventory in gallons at this facility on January 1 of the reporting year.

B.1. Enter the total gallons received from any transporter, including your own company. Write the individual totals
received from each transporter using the attachment “Collections and Deliveries, Inventory Balance Explanation”
provided with the form.

B.2. Enter the total gallons received directly from any generator, except from transporters in B.1. (e.g., an individual
delivered a 55-gallon drum).

Total. Add lines B.1. and B.2. This will be the total volume of used oil received at your facility.

C.1. Enter the total used oil delivered by any transporter, including your company, or transferred by any other means.
This is the total volume of outgoing used oil from your facility. Itemize the total gallons delivered or transferred to each
transporter using the attachment “Collections and Deliveries, Inventory Balance Explanation” provided with the form.

D. Enter the calculated (from your records) ending inventory in gallons at this facility on December 31 of the reporting
year.

E. Add the beginning inventory from line A to the total received used oil from line B. This is the subtotal which will be
used to calculate the total ending inventory in line F for the reporting year.

F. Calculate the ending inventory at this facility for the reporting year by subtracting line C.1 from subtotal in line E.

G. Compare calculated ending inventory from your records (line D) to the calculated ending inventory in this report (line
F). If the total for line F is different than line D, please write your explanation for the difference using the attachment
“Collections and Deliveries, Inventory Balance Explanation” provided with the form.

Submit the Following Financial Assurance Documents

Please submit the following financial assurance documents with this report:
• A current General Liability Insurance (ACORD) form or equivalent showing General Liability Coverage (available
from insurance broker).
• A current Environmental Pollution Liability Insurance for Third-Party Damages showing Third-Party Damages
Coverage (Used Oil Financial Form 17.7 or 17.9).

Forms are available in our official website under Financial Forms (R315-15-10 and R315-15-12) at
https://deq.utah.gov/waste-management-and-radiation-control/forms-division-of-waste-management-and-radiation-
control#used-oil.

Cleanup and Closure Cost Estimates Information

H. Select the type of financial assurance mechanism your business is using for Cleanup and Closure Cost (Select one
only):
• Letter of Credit*
• Payment Bond*
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• Insurance Policy*
• Trust Fund
*These mechanisms also require a Standby Trust Agreement.

I. Enter your unique financial instrument control number.

J. Enter the dollar amount of financial assurance provided by the financial instrument in line I.

K. Calculate the closure cost estimate adjustment value using either Method 1 or Method 2. Method one is calculated
by multiplying the previous year closure cost estimate value by the inflation factor for the current year. Method 2
requires detailed information to be submitted and approved by the Director. Also, any changes in the facility or process
requires a permit modification to be submitted to the Director for review and approval.

L. This part is used to determine if the Instrument Value is adequate or if must be increased. If the Instrument Value
from J is less than the Total Closure Cost Estimate from K (either method 1 OR 2) the Instrument Value must be
increased to equal or exceed the newly calculated Total Closure Cost Estimate. Within 60 days, submit to the Director a
written notice from the issuer of the financial mechanism documenting this increase. If the Instrument Value from J is
equal to or more than the Total Closure Cost Estimate from K (either method 1 OR 2) the Instrument Value is adequate
for this year, no changes are needed.

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Used Oil Processor/Re-Refiner
Annual Report

Note: Use this portion of the report if you are reporting used oil activities for your used oil processor/re-refiner permit.

Used Oil Inventory

A. Enter the beginning inventory and any used oil products in gallons at this facility on January 1 of the reporting year.

B.1. Enter the total gallons received from any transporter, including your own company. Write the individual totals
received from each transporter using the attachment “Collections and Deliveries, Inventory Balance Explanation”
provided with the form.

B.2. Enter the total gallons received directly from any generator, except from transporters in B.1. (e.g., an individual
delivered a 55-gallon drum).

Total. Add lines B.1. and B.2. This will be the total volume of used oil received at your facility.

C.1. Enter the total used oil processed at your facility.

C.2. Calculate the average gallons of used oil processed per day at your facility by dividing the total in line B by the total
number of days you processed used oil during the reporting year. Enter this number on this line.

C.3. Enter the total estimated gallons of used oil consumed, lost, or spilled during processing at your facility.

C.4. Enter the total gallons of waste or residues generated, including wastewater, at your facility. Write each type of
waste using the attachment “Waste or Residues, and Wastewater Balance” provided with the form.

D.1. Enter the total gallons of on-specification used oil burner fuel (Including used oil derived diesel).

D.2. Enter the total gallons of off-specification used oil burner fuel.

D.3. Enter the total gallons of non-fuel derived products (e.g., lubricating oil or asphalt materials).

D.4. Add lines D.1, D.2, and D.3, and enter the total gallons of used oil products delivered out of your facility.

E. Enter the calculated (from your records) ending inventory in gallons at this facility on December 31 of the reporting
year.

F. Add beginning inventory from line A to the total used oil received from line B. This is your subtotal in-storage.

G. Add total estimated volume of used oil consumed, lost, or spilled during processing from line C.3 to the total volume
of Used Oil Products Delivered from line D.4. This is the outgoing subtotal.

H. Calculate the ending inventory in gallons by subtracting line G from line F. Enter this number on this line.

I. Compare calculated ending inventory from your records (line E) to the calculated ending inventory in this report (line
H). If the total for line E is different than line H, please write your explanation for the difference using the attachment
“Collections and Deliveries, Inventory Balance Explanation” provided with the form.

Submit the Following Financial Assurance Documents

Please submit the following financial assurance documents with this report:
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• A current General Liability Insurance (ACORD) form or equivalent showing General Liability Coverage (available
from insurance broker).
• A current Environmental Pollution Liability Insurance for Third-Party Damages showing Third-Party Damages
Coverage (Used Oil Financial Form 17.7 or 17.9).

Forms are available in our official website under Financial Forms (R315-15-10 and R315-15-12) at
https://deq.utah.gov/waste-management-and-radiation-control/forms-division-of-waste-management-and-radiation-
control#used-oil.

Cleanup and Closure Cost Estimates Information

J. Select the type of financial assurance mechanism your business is using for Cleanup and Closure Cost (Select one
only):
• Letter of Credit*
• Payment Bond*
• Insurance Policy*
• Trust Fund
*These mechanisms also require a Standby Trust Agreement.

K. Enter your unique financial instrument control number.

L. Enter the dollar amount of financial assurance provided by the financial instrument in line I.

M. Calculate the closure cost estimate adjustment value using either Method 1 or Method 2. Method one is calculated
by multiplying the previous year closure cost estimate value by the inflation factor for the current year. Method 2
requires detailed information to be submitted and approved by the Director. Also, any changes in the facility or process
requires a permit modification to be submitted to the Director for review and approval.

N. This part is used to determine if the Instrument Value is adequate or if must be increased. If the Instrument Value
from J is less than the Total Closure Cost Estimate from K (either method 1 OR 2) the Instrument Value must be
increased to equal or exceed the newly calculated Total Closure Cost Estimate. Within 60 days, submit to the Director a
written notice from the issuer of the financial mechanism documenting this increase. If the Instrument Value from J is
equal to or more than the Total Closure Cost Estimate from K (either method 1 OR 2) the Instrument Value is adequate
for this year, no changes are needed.

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Used Oil Off-Specification Burner
Annual Report

Note: Use this portion of the report if you are reporting used oil activities for your used oil off-specification burner
permit.

Used Oil Inventory

A. Enter the beginning inventory of used oil (including off-specification) in gallons at this facility on January 1 of the
reporting year.

B. Enter the total gallons of off-specification used oil acquired. You can get this information from incoming manifests.

C. Enter the total gallons of used oil generated on site. You can get this information from company records.

D. Enter the total gallons of used oil burned at your facility, including off-specification used oil. You can calculate this
volume based on estimated consumption or more accurate method available.

E. Calculate the average gallons of used oil burned per day at your facility by dividing the total in line B by the total
number of days you burned used oil during the reporting year. Enter this value on this line.

F. Enter the ending inventory (from your records) in gallons of used oil, including off-specification, at this facility on
December 31 of the reporting year.

G. Add lines A, B, and C. This is your subtotal in-storage.

H. Burned subtotal from line D.

I. Calculate the ending inventory in gallons by subtracting line H from line G. Enter this value on this line.

J. Compare calculated ending inventory from your records (line F) to the calculated ending inventory in this report (line
I). If the total for line I is different than line F, please write your explanation for the difference using the attachment
“Collections and Deliveries, Inventory Balance Explanation” provided with the form.

Submit the Following Financial Assurance Documents

Please submit the following financial assurance documents with this report:
• A current General Liability Insurance (ACORD) form or equivalent showing General Liability Coverage (available
from insurance broker).
• A current Environmental Pollution Liability Insurance for Third-Party Damages showing Third-Party Damages
Coverage (Used Oil Financial Form 17.7 or 17.9).

Forms are available in our official website under Financial Forms (R315-15-10 and R315-15-12) at
https://deq.utah.gov/waste-management-and-radiation-control/forms-division-of-waste-management-and-radiation-
control#used-oil.

Cleanup and Closure Cost Estimates Information

K. Select the type of financial assurance mechanism your business is using for Cleanup and Closure Cost (Select one
only):
• Letter of Credit*
• Payment Bond*
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• Insurance Policy*
• Trust Fund
*These mechanisms also require a Standby Trust Agreement.

L. Enter your unique financial instrument control number.

M. Enter the dollar amount of financial assurance provided by the financial instrument in line I.

N. Calculate the closure cost estimate adjustment value using either Method 1 or Method 2. Method one is calculated
by multiplying the previous year closure cost estimate value by the inflation factor for the current year. Method 2
requires detailed information to be submitted and approved by the Director. Also, any changes in the facility or process
requires a permit modification to be submitted to the Director for review and approval.

O. This part is used to determine if the Instrument Value is adequate or if must be increased. If the Instrument Value
from M is less than the Total Closure Cost Estimate from N (either method 1 OR 2) the Instrument Value must be
increased to equal or exceed the newly calculated Total Closure Cost Estimate. Within 60 days, submit to the Director a
written notice from the issuer of the financial mechanism documenting this increase. If the Instrument Value from M is
equal to or more than the Total Closure Cost Estimate from N (either method 1 OR 2) the Instrument Value is adequate
for this year, no changes are needed.