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OMB# 2050-0024; Expires 04/30/2024United States Environmental Protec on AgencyRCRA SUBTITLE C SITE IDENTIFICATION FORM1. Reason for Submi al (Select only one.)Obtaining or upda ng an EPA ID number for on‐going regulated ac vi es (Items 10‐17 below) that will con nuefor a period of me.Submi ng as a component of the Hazardous Waste Report for (Repor ng Year) Site was a TSD facility, a reverse distributor, and/or generator of 1,000 kg of non‐acute hazardouswaste, 1 kg of acute hazardous waste, or 100 kg of acute hazardous waste spill cleanup in one ormore months of the repor ng year (or State equivalent LQG regula ons)No fying that regulated ac vity is no longer occurring at this SiteObtaining or upda ng an EPA ID number for conduc ng Electronic Manifest Broker ac vi esSubmi ng a new or revised Part A (permit) Form2. Site EPA ID Number3. Site Name4. Site Loca on AddressStreet AddressCity, Town, or VillageCountyStateCountryZip CodeLa tudeLongitude Use Lat/Long as Primary Address 5. Site Mailing AddressSame as Loca on Street AddressStreet AddressCity, Town, or VillageStateCountryZip Code6. Site Land Type her7. North American Industry Classifica on System (NAICS) Code(s) for the Site (at least 5‐digit codes)A. (Primary)C.B.D.EPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024 8. Site Contact Informa onFirst NameMILast NameCountryZip CodeExtFaxSame as Loca on AddressTitleStreet AddressCity, Town, or VillageStateEmailPhone9. Legal Owner and Operator of the Site A. Name of Site’s Legal OwnerFull NameSame as Loca on AddressDate Became Owner (mm/dd/yyyy)Owner teOtherStreet AddressCity, Town, or VillageStateCountryZip CodeExtFaxEmailPhoneCommentsB. Name of Site’s Legal Operator Full NameSame as Loca on AddressDate Became Operator (mm/dd/yyyy)Operator teOtherStreet AddressCity, Town, or VillageStateCountryZip CodeExtFaxEmailPhoneCommentsEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
OMB# 2050-0024; Expires 04/30/2024EPA ID Number10. Type of Regulated Waste Ac vity (at your site)Mark “Yes” or “No” for all current ac vi es (as of the date submi ng the form); complete any addi onal boxes as instructed.A. Hazardous Waste Ac vi es YN1. Generator of Hazardous Waste—If “Yes”, mark only one of the following—a, b, ca. LQG‐Generates, in any calendar month, 1,000 kg/mo (2,200 lb/mo) or more of non‐acutehazardous waste (includes quan es imported by importer site); or‐ Generates, in any calendar month, or accumulates at any me, more than 1 kg/mo(2.2 lb/mo) of acute hazardous waste; or‐ Generates, in any calendar month or accumulates at any me, more than 100 kg/mo(220 lb/mo) of acute hazardous spill cleanup material.b. SQG100 to 1,000 kg/mo (220‐2,200 lb/mo) of non‐acute hazardous waste and no more than1 kg (2.2 lb) of acute hazardous waste and no more than 100 kg (220 lb) of any acutehazardous spill cleanup material.c. VSQGLess than or equal to 100 kg/mo (220 lb/mo) of non‐acute hazardous waste. YN2. Short‐Term Generator (generates from a short‐term or one‐ me event and not from on‐goingprocesses). If “Yes”, provide an explana on in the Comments sec on. Note: If “Yes”, you MUST indicatethat you are a Generator of Hazardous Waste in Item 10.A.1 above. YN3. Treater, Storer or Disposer of Hazardous Waste—Note: Part B of a hazardous waste permit is requiredfor these ac vi es. YN4. Receives Hazardous Waste from Off‐site YN5 Recycler of Hazardous Wastea. Recycler who stores prior to recyclingb. Recycler who does not store prior to recycling YN6. Exempt Boiler and/or Industrial Furnace—If “Yes”, mark all that apply.a. Small Quan ty On‐site Burner Exemp onb. Smel ng, Mel ng, and Refining Furnace Exemp onB. Waste Codes for Federally Regulated Hazardous Wastes. Please list the waste codes of the Federal hazardous wasteshandled at your site. List them in the order they are presented in the regula ons (e.g. D001, D003, F007, U112). Use anaddi onal page if more spaces are needed.C. Waste Codes for State Regulated (non‐Federal) Hazardous Wastes. Please list the waste codes of the State hazardouswastes handled at your site. List them in the order they are presented in the regula ons. Use an addi onal page if morespaces are needed.EPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
OMB# 2050-0024; Expires 04/30/2024EPA ID Number11. Addi onal Regulated Waste Ac vi es (NOTE: Refer to your State regula ons to determine if a separate permit is required.)A. Other Waste Ac vi es YN1. Transporter of Hazardous Waste—If “Yes”, mark all that apply.a. Transporterb. Transfer Facility (at your site) YN2. Underground Injec on Control YN3. United States Importer of Hazardous Waste YN4. Recognized Trader—If “Yes”, mark all that apply.a. Importerb. Exporter YN5. Importer/Exporter of Spent Lead‐Acid Ba eries (SLABs) under 40 CFR 266 Subpart G—If “Yes”, mark allthat apply.a. Importerb. ExporterB. Universal Waste Ac vi es YN1. Large Quan ty Handler of Universal Waste (you accumulate 5,000 kg or more) ‐ If “Yes” mark all thatapply. Note: Refer to your State regula ons to determine what is regulated.a. Ba eriesb. Pes cidesc. Mercury containing equipmentd. Lampse. Aerosol Cansf. Other (specify)g. Other (specify) YN2. Des na on Facility for Universal Waste Note: A hazardous waste permit may be required for thisac vity.C. Used Oil Ac vi es YN1. Used Oil Transporter—If “Yes”, mark all that apply.a. Transporterb. Transfer Facility (at your site) YN2. Used Oil Processor and/or Re‐refiner—If “Yes”, mark all that apply.a. Processorb. Re‐refiner YN3. Off‐Specifica on Used Oil Burner YN4. Used Oil Fuel Marketer—If “Yes”, mark all that apply.a. Marketer Who Directs Shipment of Off‐Specifica on Used Oil to Off‐Specifica on Used Oil Burnerb. Marketer Who First Claims the Used Oil Meets the Specifica onsEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024D. Pharmaceu cal Ac vi es YN1. Opera ng under 40 CFR Part 266, Subpart P for the management of hazardous waste pharmaceu ‐cals—if “Yes”, mark only one. Note: See the item‐by‐item instruc ons for defini ons of healthcare facilityand reverse distributor.a. Healthcare Facilityb. Reverse Distributor YN2. Withdrawing from opera ng under 40 CFR Part 266, Subpart P for the management of hazardous wastepharmaceu cals. Note: You may only withdraw if you are a healthcare facility that is a VSQG for all ofyour hazardous waste, including hazardous waste pharmaceu cals.12. Eligible Academic En es with Laboratories—No fica on for op ng into or withdrawing from managing laboratory hazardouswastes pursuant to 40 CFR Part 262, Subpart K. YNA. Op ng into or currently opera ng under 40 CFR Part 262, Subpart K for the management of hazardouswastes in laboratories— If “Yes”, mark all that apply. Note: See the item‐by‐item instruc ons for defini‐ons of types of eligible academic en es.1. College or University2. Teaching Hospital that is owned by or has a formal wri en affilia on with a college or university3. Non‐profit Ins tute that is owned by or has a formal wri en affilia on with a college or university YNB. Withdrawing from 40 CFR Part 262, Subpart K for the management of hazardous wastes in laboratories.13. Episodic Genera on YN Are you an SQG or VSQG genera ng hazardous waste from a planned or unplanned episodic event, las ngno more than 60 days, that moves you to a higher generator category. If “Yes”, you must fill out theAddendum for Episodic Generator.14. LQG Consolida on of VSQG Hazardous Waste YN Are you an LQG no fying of consolida ng VSQG Hazardous Waste Under the Control of the Same Personpursuant to 40 CFR 262.17(f)? If “Yes”, you must fill out the Addendum for LQG Consolida on of VSQGhazardous waste.15. No fica on of LQG Site Closure for a Central Accumula on Area (CAA) (op onal) OR En re Facility (required) YN LQG Site Closure of a Central Accumula on Area (CAA) or En re Facility.A.Central Accumula on Area (CAA) or En re FacilityB. Expected closure date: mm/dd/yyyyC. Reques ng new closure date: mm/dd/yyyyD. Date closed : mm/dd/yyyy1. 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)EPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/202416. No fica on of Hazardous Secondary Material (HSM) Ac vity YN Are you no fying under 40 CFR 260.42 that you will begin managing, are managing, or will stop managinghazardous secondary material under 40 CFR 260.30, 40 CFR 261.4(a)(23), (24), (25), or (27)? If “Yes”, youmust fill out the Addendum to the Site Iden fica on Form for Managing Hazardous Secondary Material.17. Electronic Manifest Broker YNAre you no fying as a person, as defined in 40 CFR 260.10, elec ng to use the EPA electronic manifest sys‐tem to obtain, complete, and transmit an electronic manifest under a contractual rela onship with a haz‐ardous waste generator?18. Comments (include item number for each comment)19. Cer fica on I cer fy under penalty of law that this document and all a achments were prepared under my direc on or su‐pervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the informa onsubmi ed. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gath‐ering the informa on, the informa on submi ed is, to the best of my knowledge and belief, true, accurate, and complete. I amaware that there are significant penal es for submi ng false informa on, including the possibility of fines and imprisonment forknowing viola ons. Note: For the RCRA Hazardous Waste Part A permit Applica on, all owners and operators must sign (see 40CFR 270.10(b) and 270.11).Signature of legal owner, operator or authorized representa veDate (mm/dd/yyyy)Printed Name (First, Middle Ini al Last)TitleEmailSignature of legal owner, operator or authorized representa veDate (mm/dd/yyyy)Printed Name (First, Middle Ini al Last)TitleEmailEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024ADDENDUM TO THE SITE IDENTIFICATION FORM:NOTIFICATION OF HAZARDOUS SECONDARY MATERIAL ACTIVITYONLY fill out this form if: You are located in a State that allows you to manage excluded hazardous secondary material (HSM) under 40 CFR260.30, 261.4(a)(23), (24), (25), or (27) (or state equivalent; See waste-rule-effect for a list of eligible states; AND You are or will be managing excluded HSM in compliance with 40 CFR 260.30, 261.4(a)(23), (24), (25), or (27) (orstate equivalent) or have stopped managing excluded HSM in compliance with the exclusion(s) and do not expectto manage any amount of excluded HSM under the exclusion(s) for at least one year. Do not include any infor‐ma on regarding your hazardous waste ac vi es in this sec on. Note: If your facility was granted a solid wastevariance under 40 CFR 260.30 prior to July 13, 2015, your management of HSM under 40 CFR 260.30 is grandfa‐thered under the previous regula ons and you are not required to no fy for the HSM management ac vity exclud‐ed under 40 CFR 260.30.1. Reason for No fica on (Include dates where requested)Facility will begin managing excluded HSM as of (mm/dd/yyyy).Facility is s ll managing excluded HSM/re‐no fying as required by March 1 of each even‐numbered year.Facility has stopped managing excluded HSM as of (mm/dd/yyyy) and is no fying as required.2. Descrip on of Excluded HSM Ac vity. Please list the appropriate codes (see Code List sec on of the instruc ons) andquan es, in short tons, to describe your excluded HSM ac vity ONLY (do not include any informa on regarding yourhazardous wastes). Use addi onal pages if more space is needed.A. FacilityCodeB. Waste Code(s) for HSMEPA Form 8700‐12, 8700‐13 A/B, 8700‐23C. Es mate Short Tons D. Actual Short Tons ofE. Land‐based Unitof excluded HSM toexcluded HSM that wasbe managed annually managed during the most Coderecent odd‐numbered yearPage of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024ADDENDUM TO THE SITE IDENTIFICATION FORM:EPISODIC GENERATORONLY fill out this form if: You are an SQG or VSQG genera ng hazardous waste from a planned or unplanned episodic event, las ng nomore then 60 days, that moves the generator to a higher generator category pursuant to 40 CFR 262 Subpart L.Note: Only one planned and one unplanned episodic event are allowed within one year; otherwise, you mustfollow the requirements of the higher generator category. Use addi onal pages if more space is needed.Episodic Event1. Planned2. UnplannedExcess chemical inventory removal Tank cleanouts Short‐term construc on or demoli onEquipment maintenance during plant shutdownsOther3. Emergency Contact Phone5. Beginning Date Accidental spills Produc on process upsetsProduct recalls“Acts of nature” (Tornado, hurricane, flood, etc.)Other4. Emergency Contact Name(mm/dd/yyyy)6. End Date(mm/dd/yyyy)Waste 17. Waste Descrip on8. Es mated Quan ty (in pounds)9. Federal and/or State Hazardous Waste CodesWaste 27. Waste Descrip on8. Es mated Quan ty (in pounds)9. Federal and/or State Hazardous Waste CodesWaste 37. Waste Descrip on8. Es mated Quan ty (in pounds)9. Federal and/or State Hazardous Waste CodesEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024ADDENDUM TO THE SITE IDENTIFICATION FORM:LQG CONSOLIDATION OF VSQG HAZARDOUS WASTEONLY fill out this form if: You are an LQG receiving hazardous waste from VSQGs under the control of the same person. Use addi onal pag‐es if more space is needed.VSQG 11. EPA ID Number (if assigned)2. Name3. Street Address4. City, Town, or Village5. State7. Contact Phone Number8. Contact Name6. Zip Code9. EmailVSQG 21. EPA ID Number (if assigned)2. Name3. Street Address4. City, Town, or Village5. State7. Contact Phone Number8. Contact Name6. Zip Code9. EmailVSQG 31. EPA ID Number (if assigned)2. Name3. Street Address4. City, Town, or Village5. State7. Contact Phone Number8. Contact Name6. Zip Code9. EmailEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
OMB# 2050-0024; Expires 04/30/2024EPA ID NumberUnited States Environmental Protec on AgencyHAZARDOUS WASTE REPORT (reporng cycle)WASTE GENERATION AND MANAGEMENT (GM) FORM1. Waste Characteris csA. Waste Descrip onB. EPA Hazardous Waste Code(s)C. State Hazardous Waste Code(s)D. Source CodeManagement Method (G25)Country Code (G62)E. Form CodeF. Waste Minimiza on CodeG. Radioac ve MixedH. Quan tyUOM Density Ylbs/galN sg2. On‐site Genera on and Management of Hazardous Waste YNWas any of this waste that was generated at this facility treated, disposed, and/or recycled on‐site? If yes,con nue to On‐site Process System 1.Process System 1Management Method CodeQuan tyProcess System 2Management Method CodeQuan ty3. Off‐site Shipment of Hazardous Waste YNA. Was any of this waste that was generated at this facility shipped off‐site for treatment, disposal, or recy‐cling? If yes, con nue to Site 1.Site 1B. EPA ID of facility to which waste was shippedC. Management Method CodeD. Total Quan ty ShippedC. Management Method CodeD. Total Quan ty ShippedC. Management Method CodeD. Total Quan ty ShippedSite 2B. EPA ID of facility to which waste was shippedSite 3B. EPA ID of facility to which waste was shipped4. CommentsEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024United States Environmental Protec on AgencyHAZARDOUS WASTE REPORT (reporng year)WASTE RECEIVED FROM OFF‐SITE (WR) FORM1. Waste 1A. Waste Descrip onB. EPA Hazardous Waste Code(s)C. State Hazardous Waste Code(s)D. EPA ID NumberG. Quan tyE. Form CodeUOMDensityF. Management Code lbs/galsg2. Waste 2A. Waste Descrip onB. EPA Hazardous Waste Code(s)C. State Hazardous Waste Code(s)D. EPA ID NumberG. Quan tyE. Form CodeUOMDensityF. Management Code lbs/galsg3. Waste 3A. Waste Descrip onB. EPA Hazardous Waste Code(s)C. State Hazardous Waste Code(s)D. EPA ID NumberG. Quan tyE. Form CodeUOMDensityF. Management Code lbs/galsg4. CommentsEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024United States Environmental Protec on AgencyHAZARDOUS WASTE REPORTOFF‐SITE IDENTIFICATION (OI) FORM1. Site 1A. EPA ID Number of Off‐site Installa on or TransporterB. Name of Off‐site Installa on or Transporter GeneratorC. Handler Type (mark all that apply)TransporterReceiving FacilityD. Address of Off‐site Installa onStreet AddressCity, Town, or VillageStateZip CodeCountry2. Site 2A. EPA ID Number of Off‐site Installa on or TransporterB. Name of Off‐site Installa on or Transporter GeneratorC. Handler Type (mark all that apply)TransporterReceiving FacilityD. Address of Off‐site Installa onStreet AddressCity, Town, or VillageStateZip CodeCountry3. Site 3A. EPA ID Number of Off‐site Installa on or TransporterB. Name of Off‐site Installa on or TransporterC. Handler Type (mark all that apply) GeneratorTransporterReceiving FacilityD. Address of Off‐site Installa onStreet AddressCity, Town, or VillageStateZip CodeCountry4. CommentsEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/2024United States Environmental Protec on AgencyHAZARDOUS WASTE PERMIT PART A FORM1. Facility Permit ContactFirst NameMILast NameExtFaxTitleEmailPhone2. Facility Permit Contact Mailing AddressStreet AddressCity, Town, or VillageStateCountryZip Code3. Facility Existence Date (mm/dd/yyyy)4. Other Environmental PermitsA. Permit TypeB. Permit NumberC. Descrip on5. Nature of BusinessEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
EPA ID NumberOMB# 2050-0024; Expires 04/30/20246. Process Codes and Design Capaci esLineNumberA. Process CodeB. Process Design Capacity(1) Amount(2) Unit ofMeasureC. Process TotalNumber of UnitsD. Unit Name7. Descrip on of Hazardous Wastes (Enter codes for Items 7.A, 7.C and 7.D(1) )Line No.A. EPA HazardousWaste No.B. Es matedAnnualQty ofWasteD. ProcessesC. Unit ofMeasure(2)(1) Process CodesProcess Descrip on(if code is not entered in 7.D1))8. MapA ach to this applica on a topographical map, or other equivalent map, of the area extending to at least one mile beyondproperty boundaries. The map must show the outline of the facility, the loca on of each of its exis ng intake and dischargestructures, each of its hazardous waste treatment, storage, or disposal facili es, and each well where it injects fluids under‐ground. Include all spring, rivers, and other surface water bodies in this map area. See instruc ons for precise require‐ments.9. Facility DrawingAll exis ng facili es must include a scale drawing of the facility. See instruc ons for more detail.10. PhotographsAll exis ng facili es must include photographs (aerial or ground‐level) that clearly delineate all exis ng structures; exis ngstorage, treatment, and disposal areas; and sites of future storage, treatment, or disposal areas. See instruc ons for moredetail.11. CommentsEPA Form 8700‐12, 8700‐13 A/B, 8700‐23Page of
(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.
