DWM7072A Hazardous Waste Annual Report Addendum ... - …



Kentucky Department for Environmental Protection Division of Waste ManagementHazardous Waste Branch300 Sower Blvd, Frankfort, KY 40601(502) 564-6716Hazardous Waste Annual Report Addendum(EPA Form 8700-13 A/B)FORM 1: Identification and CertificationFOR OFFICIAL USE ONLY.DO NOT WRITE IN THIS SPACE.I.Site ID NumbersA. EPA ID Number: KY FORMTEXT ?? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???B. AGENCY INTEREST (AI) Number: FORMTEXT ?????II. Reporting YearA. Reporting Year: January 1 through December 31, 20 FORMTEXT ?????III.Legal Landowner of the Real PropertyName of Landowner: ______Date Became Owner: (mm/dd/yyyy) FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????Landowner Type: FORMCHECKBOX Private FORMCHECKBOX Federal FORMCHECKBOX State FORMCHECKBOX Municipal FORMCHECKBOX County FORMCHECKBOX OtherPhone Number: _____Phone Number Extension: ______Street Address or P. O. Box: ______City: ______State: ______Country: ______Zip Code: ______IV.Type of Regulated Waste ActivityA. Hazardous Waste ActivitiesB. Universal Waste ActivitiesC. Used Oil ActivitiesGenerator of Hazardous WasteIs this a one-time-only or episodic hazardous waste activity report? FORMCHECKBOX Yes FORMCHECKBOX NoDid you have a status change during the year? FORMCHECKBOX Yes FORMCHECKBOX NoFuel Burner of Hazardous Waste for Energy Recovery FORMCHECKBOX Yes FORMCHECKBOX No(If “Yes”, mark all that apply) FORMCHECKBOX a. Industrial Boiler FORMCHECKBOX b. Industrial Furnace Large Quantity Universal Waste Handler (over 11,000 pounds on-site storage) FORMCHECKBOX Yes FORMCHECKBOX No If yes, mark all that applyGenerate AccumulateBatteries FORMCHECKBOX FORMCHECKBOX Pesticides FORMCHECKBOX FORMCHECKBOX Mercury Containing Equipment FORMCHECKBOX FORMCHECKBOX Lamps (includes fluorescent lamps) FORMCHECKBOX FORMCHECKBOX Other: (specify) ______ FORMCHECKBOX FORMCHECKBOX Other: (specify) ______ FORMCHECKBOX FORMCHECKBOX Off-Specification Used Oil Burner FORMCHECKBOX Yes FORMCHECKBOX No If “Yes,” mark all that apply FORMCHECKBOX a. Utility Boiler FORMCHECKBOX b. Industrial Boiler FORMCHECKBOX c. Industrial FurnaceV. Comments (Additional Information that will clarify any item in this report.)Click here to enter text.Kentucky Department for Environmental Protection Division of Waste ManagementHazardous Waste Branch300 Sower Blvd, Frankfort, KY 40601(502) 564-6716Hazardous Waste Annual Report Addendum(EPA Form 8700-13 A/B)FORM 2: Waste Generation and Management (EPA GM Form) A. EPA ID Number: KY FORMTEXT ?? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???B. AGENCY INTEREST (AI) Number: FORMTEXT ?????Waste Description (See instructions.) Check one: FORMCHECKBOX Liquid FORMCHECKBOX Solid(1) (General) ________________________________________________________________________________(2) (Item 9b of manifest) ________________________________________________________________________Is this waste both hazardous and radioactive? FORMCHECKBOX Yes FORMCHECKBOX NoQuantity Generated in Report Year______________________________poundsEnter the value used to convert this waste to pounds(Leave blank if waste amount is already listed in pounds)_______________________________________________ON-SITE MANAGEMENTWas any of this waste managed on-site by treatment FORMCHECKBOX , recycling FORMCHECKBOX , disposal FORMCHECKBOX , or by discharge to a sewer or publicly owned treatment works (POTW) FORMCHECKBOX ? Check One. FORMCHECKBOX Yes – Complete On-site Process System block(s) FORMCHECKBOX No – Skip to Waste Shipped Off-siteWASTE SHIPPED OFF-SITEWas any of this waste shipped off site in 20__ for treatment, disposal, or recycling? FORMCHECKBOX Yes – Continue completing this form and Form 4. FORMCHECKBOX No – Form 2 is complete.Site1Name of receiving facility:______________________________EPA ID Number of receiving facility:______________________________Off-Site Management Method CodeH ____Total Quantity Shipped in 20_______________________ poundsSite2Name of receiving facility:______________________________EPA ID Number of receiving facility:______________________________Off-Site Management Method CodeH ____Total Quantity Shipped in 20_______________________ poundsKentucky Department for Environmental Protection Division of Waste ManagementHazardous Waste Branch300 Sower Blvd, Frankfort, KY 40601(502) 564-6716Hazardous Waste Annual Report Addendum(EPA Form 8700-13 A/B)FORM 3: Waste Received From Off Site (EPA WR Form)A. EPA ID Number: KY FORMTEXT ?? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???B. AGENCY INTEREST (AI) Number: FORMTEXT ?????Waste1Waste Description (See instructions.) Check one: FORMCHECKBOX Liquid FORMCHECKBOX Solid (1) (General) ________________________________________________________________________(2) (Manifest) ________________________________________________________________________Is this waste both hazardous and radioactive? FORMCHECKBOX Yes FORMCHECKBOX NoName of generator from which this waste was received_____________________________________________EPA ID Number of generator from which this waste was received_____________________________________________Waste2Waste Description (See instructions.) Check one: FORMCHECKBOX Liquid FORMCHECKBOX Solid (1) (General) _________________________________________________________________________(2) (Manifest)_________________________________________________________________________Is this waste both hazardous and radioactive? FORMCHECKBOX Yes FORMCHECKBOX NoName of generator from which this waste was received_____________________________________________EPA ID Number of generator from which this waste was received_____________________________________________Waste3Waste Description (See instructions.) Check one: FORMCHECKBOX Liquid FORMCHECKBOX Solid (1) (General) _________________________________________________________________________(2) (Manifest) ________________________________________________________________________Is this waste both hazardous and radioactive? FORMCHECKBOX Yes FORMCHECKBOX NoName of generator from which this waste was received_____________________________________________EPA ID Number of generator from which this waste was received_____________________________________________Kentucky Department for Environmental Protection Division of Waste ManagementHazardous Waste Branch300 Sower Blvd, Frankfort, KY 40601(502) 564-6716Hazardous Waste Annual Report Addendum(EPA Form 8700-13 A/B)FORM 4: Summary of Waste Shipped Off Site (EPA OI Form)A. EPA ID Number: KY FORMTEXT ?? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???B. AGENCY INTEREST (AI) Number: FORMTEXT ?????List All Receiving FacilitiesList each facility only once.Total Number of Manifested ShipmentsTotal Pounds Shippedfor Reporting YearEPA ID Number _________________________________________Facility Name ___________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Facility Name ___________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Facility Name ___________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Facility Name ___________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Facility Name ___________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Facility Name ___________________________________________ FORMTEXT ????? FORMTEXT ????? Total FORMTEXT ????? FORMTEXT ?????List All Primary TransportersList each primary transporter only once. Do not list secondary transporters.Total Number of Manifested ShipmentsTotal Pounds Shipped for Reporting YearContainer TypesEPA ID Number _________________________________________Transporter Name _______________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Transporter Name _______________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Transporter Name________________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Transporter Name _______________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Kentucky Department for Environmental Protection Division of Waste ManagementHazardous Waste Branch300 Sower Blvd, Frankfort, KY 40601(502) 564-6716Hazardous Waste Annual Report Addendum(EPA Form 8700-13 A/B)FORM 5: Summary of Waste Shipped To Your SiteA. EPA ID Number: KY FORMTEXT ?? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???B. AGENCY INTEREST (AI) Number: FORMTEXT ?????List All Generators that Sent Waste to Your FacilityList each facility only once.Total Number of Manifested ShipmentsTotal Pounds Shippedfor Reporting YearEPA ID Number _________________________________________Generator Name ________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Generator Name _________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Generator Name ________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Generator Name ________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Generator Name ________________________________________ FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Generator Name ________________________________________ FORMTEXT ????? FORMTEXT ????? Total FORMTEXT ????? FORMTEXT ?????List All Primary TransportersList each primary transporter only once. Do not list secondary transporters.Total Number of Manifested ShipmentsTotal Pounds Shipped for Reporting YearContainer TypesEPA ID Number _________________________________________Transporter Name _______________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Transporter Name _______________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Transporter Name________________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EPA ID Number _________________________________________Transporter Name _______________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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