Environmental Management Bureau Region 7



ESTABLISHMENT CATEGORIZATION CHECKLIST FORMFOR PCO ACCREDITATIONPlease check the appropriate checkboxes if your company possessed/used any of the following raw chemicals or as chemical components in a certain raw chemical.1,4- CHLOROBENZENECHLOROP1CRINMETHYL CHLORIDE1,2- DIBROMOETHANECHROMIUM COMPOUNDSMETHYLENECHLORIDEO-DICHLOROBENZENECYANIDE COMPOUNDSMIREX1,4- DICHLOROBENZENEDIETHYL SULFATEPENTACHLOROPHENOL1,2 DICHLOROETHANEETHYLENE DIBROMIDEPERCHLOROETHYLENE1,2 DIPHENYLHYDRAZINEETHYLENE OXIDEPHENIC ACID3-HYDROXYPHENOLGLUTARALDEHYDEPHOSGENEANTIMONYPENTACHLOR1DEFORMALDEHYDEPTHALIC ANHYDRIDEARSENIC COMPOUNDSHALONSPOLYBROMINATEDBIPHENYLSASBESTOSHEXACHLOROBENZENEPOLYCHLORINATEDBIPHENYLSBENZENEHEXACHLOROETHANE1,1,1 -TRICHLOROETHANEBERYLLIUM COMPOUNDSHYDRAZINETRICHLOROETHYLENECADMIUM COMPOUNDSLEAD COMPOUNDSTRIBUTYLTINCARBON TETRACHLORIDEMercaptobenzothiazole (MBT)SELENIUMCHLORINATED ETHERSMERCAPTAN,PERCHLOROMETHYLVINYL CHLORIDECHLOROFLUORO CARBONSMERCURY COMPOUNDSMETHYL CHLORIDE N/ANote: Above listed chemicals do not include chemicals contained in a consumer product e.g. fluorescent lamp, lead acid batteries, etc.Please check the appropriate checkboxes of the Hazardous Wastes generated and indicate the corresponding estimated generation per year.Hazardous Waste NumberWaste TypeGeneration(kg/yr)A101Cyanide WasteL406PCBs WasteM502Asbestos WasteM501-M503Medical WasteD401-D499Waste with Inorganic ChemicalsE501-E599Reactive Chemical WasteF602-F699Inks/Dyes/Pigments/Paint/Resins/Latex/Adhesives/Organic SludgeG703-G704Waste Organic SolventsK301-K303Stabilized WasteL401-L402Other Organic ChemicalsM504-M506Miscellaneous WasteB201-B299Acid WasteC301-C399Alkali Waste1101Oil WasteJ201Empty Chemical ContainersH802Putrescible WasteD407Busted fluorescent lamps N/APlease check the appropriate checkboxes if your company provides any of the following services to another company/clients, to wit:Centralized Material Recovery Facility (MRF) Solid wastes treatment or processing facilities Sanitary Landfill N/AWastewater generation: Domestic Wastewater:________m3/dayProcess Wastewater:_________m3/dayAir Pollution Source Equipments (APSEs):Ex. Generator sets, Fossil fuel fired boilers, Fossil fuel fired kiln dryers, Grinders, Crushers, etc.Name of APSEFuel TypeRated Capacity(Hp or kW or kVA)1)2)3)4)5)Please attached additional sheets if necessaryPlease check the appropriate checkboxes if your wastewater contains any of the following pollutants/contaminants/characteristics:Arsenic CadmiumChromium (hexavalent)CyanideLeadMercury (total)PCBsFormaldehyde Wastewater has a raw BOD of greater than or equal to 3,000 mg/L N/APlease check the appropriate checkboxes if your company provides any of the following services to another company/clients, to wit: Transport of Sludge Treatment of Sludge Transport of Hazardous Wastes Treatment, Storage and Disposal (TSD) of Hazardous Wastes Transport or treatment of wastewater, sewage and/or septage N/AEstablishment category based on the above information per DAO 2014-02:___________..______________________________ Name and Signature of PCO ................
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