DSHW-2024-006966

Used Oil Annual Report
For January 1st to December 31st
Annual reports shall be submitted to the Director no later than March 1, of the year following the reported activities.
Mail to: State of Utah, Department of Environmental Quality
Division of Waste Management and Radiation Control
P.O. Box 144880
Salt Lake City, UT 84114-4880
Phone: [phone]
In Person: State of Utah, Department of Environmental Quality
Division of Waste Management and Radiation Control
195 North 1950 West
Multi-Agency State Office Building, 2nd Floor
Salt Lake City, Utah 84116
Email to: [e-mail]
Revised March 2024
Permit Information
Select the type(s) of permit(s); then, complete and submit required pages and documents for each type of permit.
Type of Permit (Select from Dropdown Menu) Used Oil Permit Number
Used Oil Permittee Full Legal Name (individual person or legal business entity – no DBAs) Permittee EPA ID No (i.e., UTR123456789)
Permitted Facility Principal Place of Business (Street, City, State, Zip Code) Main Telephone No. (Area code + 7 digits)
Annual Report Contact Name
Mailing Address (If different than principal place of business address) Annual Report Contact Telephone No. (Area code + 7 digits)
Annual Report Contact Email Address
Type of Permit (Select from Dropdown Menu) Used Oil Permit Number
Used Oil Permittee Full Legal Name (individual person or legal business entity – no DBAs) Permittee EPA ID No (i.e., UTR123456789)
Permitted Facility Principal Place of Business (Street, City, State, Zip Code) Main Telephone No. (Area code + 7 digits)
Annual Report Contact Name
Mailing Address (If different than principal place of business address) Annual Report Contact Telephone No. (Area code + 7 digits)
Annual Report Contact Email Address
Type of Permit (Select from Dropdown Menu) Used Oil Permit Number
Used Oil Permittee Full Legal Name (individual person or legal business entity – no DBAs) Permittee EPA ID No (i.e., UTR123456789)
Permitted Facility Principal Place of Business (Street, City, State, Zip Code) Main Telephone No. (Area code + 7 digits)
Annual Report Contact Name
Mailing Address (If different than principal place of business address) Annual Report Contact Telephone No. (Area code + 7 digits)
Annual Report Contact Email Address
Certification
By signing this document, I certify that (i) I am duly authorized to act on behalf of the business; and (ii) that all the information contained in this document is true
and correct to the best of my knowledge, information, and belief. I further certify that I am aware that it is a violation of law to submit false information to the
Division.
I hereby certify the forgoing is true and correct.
Name of Authorized Person Signing Annual Report (printed) Title
Signature Date
FY2023
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Used Oil Transporter
Annual Report
Used Oil Collections and Deliveries Summary
A.Total gallons collected outside Utah, and then transported to a used oil facility in Utah (imports). Itemize the individual
totals collected from each facility using the attachment provided with this form.
B.Total gallons collected in Utah, and then transported to a used oil facility in Utah. Itemize the individual totals collected
from each facility using the attachment provided with this form.
C.Total gallons collected in Utah, and then transported to a used oil facility outside of Utah (exports). Itemize the individual
totals collected from each facility using the attachment provided with this form.
I.Total volume of Collections in gallons from lines A and B ►
D.Total gallons delivered in Utah to other transporters, transfer facilities, processors, burners, and other approved facilities.
Itemize the individual totals delivered to each facility using the attachment provided with this form.
E.Total gallons delivered outside Utah to other transporters, transfer facilities, processors, burners, and other approved
facilities (exports). Itemize the individual totals delivered to each facility using the attachment provided with this form.
II.Total volume of Deliveries in gallons from lines C and D ►
F.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 provided with this form.
Used Oil Filter Handling Quantity of Used Oil
Filters
Volume Estimates:
(Drums to number of filters)
One 55-gallon drum of crushed used oil filters = approximately 400 used oil filters
One 55-gallon drum of uncrushed used oil filters = approximately 250 used oil filters
One ton of drained used oil filters = approximately 2,350 used oil filters
G.Approximate number of used oil filters collected from generators or facilities in Utah.
H.Approximate number of used oil filters collected from generators or facilities outside Utah and transported to a facility in
Utah.
I.Disposition of collected used oil filters.In Utah Outside Utah
1.Quantity of filters transferred to another permitted used oil facility.
2.Quantity of filters transferred directly to a waste-to-energy facility.
3.Quantity of filters transferred directly to a metal foundry for recycling.
4.Quantity of filters disposed to a landfill
5.Quantity of filters disposed using other disposal methods
Total quantity of disposed Used Oil Filters from lines H.1 thru H.5 ►
J.Provide the name(s) of each facility where filters were transferred, and describe how the filters were managed (e.g., crushed and recycled, shredded, and so
on) using the attachment provided with this form.
Submit the Following Financial Assurance Documents
Current General Liability Insurance (ACORD) form or equivalent showing General Liability Coverage (available from insurance broker).
Curren Environmental Pollution Liability Insurance for Third-Party Damages showing Third-Party Damages Coverage (Used Oil Financial Form 17.6).
Used Oil Transfer Facility
Annual Report
Used Oil Inventory
A.Beginning inventory in gallons at this facility on January 1 of the reporting year.
B.Used Oil Received
1.Total gallons received from any transporter, including your own company. Itemize the individual totals received from
each transporter using the attachment provided with this form.
2.Total gallons received directly from any generator (Did anyone, other than the transporters itemized on B.1., bring used
oil to your facility? (e.g., an individual delivered a 55-gallon drum).
Total volume received from lines B.1, and B.2 ►
C.Used Oil Delivered
1.Total gallons delivered by any transporter, including your company, or transferred by any other means. Itemize the total
gallons delivered or transferred to each transporter using the attachment provided with this form.
Total volume delivered from line C.1 ►
D.Ending inventory in gallons at this facility on December 31 of the reporting year.
E.Subtotal (Add beginning inventory from line A to the total received from line B).
F.Calculated ending inventory in gallons (Subtract line C.1 from line E).
Total Ending Inventory ►
G.Ending Inventory Comparison: If the total for line F (Calculated ending inventory) is different than line D (Ending inventory on December 31st), please provide
an explanation using the attachment provided with this form.
Submit the Following Financial Assurance Documents
Current ACORD form or equivalent (available from insurance broker) showing General Liability Coverage.
Current Environmental Pollution Liability showing Third-Party Damages Coverage (Used Oil Financial Form 17.7 or 17.9).
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): *These mechanisms also require a
Standby Trust Agreement.
Letter of Credit * Payment Bond *
Insurance Policy * Trust Fund
I.Financial Instrument Control Number (Unique identifying number document)
J.Dollar amount of financial assurance provided by this financial instrument.
Instrument Value ► $
K.Closure Cost Estimate Adjustment: (Complete either Method 1 OR Method 2 below then complete section I)
1.Method 1: Inflation Factor Adjustment $ X 1.037 = $
Enter Last Year’s Total
Closure Cost Estimate Inflation Factor Total Closure Cost
2.Method 2: Recalculated Engineering Closure Cost
Estimate Recalculated Engineering Closure Cost Estimate ► $
Note: This method 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.Financial Assurance Cost Estimate Summary: 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 or more than 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 Facility
Annual Report
Used Oil Inventory
A.Beginning inventory and any used oil products in gallons at this facility on January 1 of the reporting year.
B.Used Oil Received
1.Total gallons received from any transporter, including your own company. Itemize the individual totals received from
each transporter using the corresponding attachment provided with this form.
2.Total gallons received directly from any generator (Did anyone, other than the transporters itemized on B.1., bring used
oil to your facility? (e.g., an individual delivered a 55-gallon drum).
Total volume received from lines B.1, and B.2 ►
C.Used Oil Processed
1.Total gallons of used oil processed.
2.Average gallons of used oil processed per day (Divide total in B above by the total number of days you processed used
oil during the reporting year).
3.Total estimated gallons of used oil consumed, lost, or spilled during processing
4.Total gallons of waste or residues generated, including wastewater. Itemize each type of waste using the attachment
provided with this form.
D.Used Oil Produced and Delivered (All sales and transfers)
1.Total gallons of on-specification used oil burner fuel (Including used oil derived diesel).
2.Total gallons of off-specification used oil burner fuel.
3.Total gallons of non-fuel derived products (e.g., lubricating oil or asphalt materials).
4.Total gallons of used oil products delivered (Add lines D.1, D.2, and D.3).
E.Ending inventory in gallons at this facility on December 31 of the reporting year.
F.In Storage subtotal (Add beginning inventory from line A to the total used oil received from line B).
G.Outgoing subtotal (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).
H.Calculated Ending inventory in gallons (Subtract line G from line F).
I.Ending Inventory Comparison: If the total for line H (Calculated ending inventory) is different than line E (Ending inventory on December 31st of the reporting
year), please provide an explanation using the attachment provided with this form.
Submit the Following Financial Assurance Documents
Current ACORD form or equivalent (available from insurance broker) showing General Liability Coverage.
Current Environmental Pollution Liability showing Third-Party Damages Coverage (Used Oil Financial Form 17.7 or 17.9).
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): *These mechanisms also require a
Standby Trust Agreement.
Letter of Credit * Payment Bond *
Insurance Policy * Trust Fund
K.Financial Instrument Control Number (Unique identifying number document)
L.Dollar amount of financial assurance provided by this financial instrument.
Instrument Value ► $
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M.Closure Cost Estimate Adjustment: (Complete either Method 1 OR Method 2 below then complete section I)
1.Method 1: Inflation Factor Adjustment $ X 1.037 = $
Enter Last Year’s Total
Closure Cost Estimate Inflation Factor Total Closure Cost
2.Method 2: Recalculated Engineering Closure Cost
Estimate Recalculated Engineering Closure Cost Estimate ► $
Note: This method 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.Financial Assurance Cost Estimate Summary: If the Instrument Value from L is less than the Total Closure Cost Estimate from M (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 L is equal or more than Total Closure Cost Estimate
from M (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
Used Oil Inventory
A.Beginning inventory of used oil (including off-specification) in gallons at this facility on January 1 of the reporting year.
B.Total gallons of off-specification used oil acquired (Documented on incoming manifests).
C.Total gallons of used oil generated on site (Documented on company records).
D.Total gallons of used oil burned (including off-specification) (Based on estimated consumption or more accurate method
available).
E.Average daily gallons of used oil burned (including off-specification) as of December 31st of the reporting year.
F.Ending inventory in gallons of used oil (including off-specification) at this facility on December 31 of the reporting year.
G.In Storage subtotal (Add lines A, B, and C).
H.Burned subtotal (From line D).
I.Calculated Ending inventory in gallons (Subtract line H from line G).
J.Ending Inventory Comparison: If the total for line I (Calculated ending inventory) is different than line F (Ending inventory on December 31st of the reporting
year), please provide explanation using the attachment provided with this form.
Submit the Following Financial Assurance Documents
Current ACORD form or equivalent (available from insurance broker) showing General Liability Coverage.
Current Environmental Pollution Liability showing Third-Party Damages Coverage (Used Oil Financial Form 17.7 or 17.9).
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): *These mechanisms also require a
Standby Trust Agreement.
Letter of Credit * Payment Bond *
Insurance Policy * Trust Fund
L.Financial Instrument Control Number (Unique identifying number document)
M.Dollar amount of financial assurance provided by this financial instrument.
Instrument Value ► $
N.Closure Cost Estimate Adjustment: (Complete either Method 1 OR Method 2 below then complete section I)
1.Method 1: Inflation Factor Adjustment $ X 1.037 = $
Enter Last Year’s Total
Closure Cost Estimate Inflation Factor Total Closure Cost
2.Method 2: Recalculated Engineering Closure Cost
Estimate Recalculated Engineering Closure Cost Estimate ► $
Note: This method 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.Financial Assurance Cost Estimate Summary: 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 or more than Total Closure Cost Estimate
from N (either method 1 OR 2) the Instrument Value is adequate for this year, no changes are needed.
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Annual Report – Attachment No.
Collections and Deliveries,
Inventory Balance Explanation
List of Collections and Deliveries (Name of Generator or Facility, and Address) Gallons
Used Oil Inventory Balance Explanation
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Annual Report – Attachment No.
Used Oil Filter Handling
Name of the Facility where Filters Were Transferred to Describe How the Filters Were Managed
(i.e., crushed and recycled, shredded, and so on)
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Annual Report – Attachment No.
Waste or Residues, and Wastewater Balance
Type of Waste or Residue, and Wastewater Gallons
Total gallons of Waste or Residue, and Wastewater Generated ►
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Annual Report – Attachment No.
(Extra Page)
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