DWM7037A Registration of Hazardous Waste Activity …



Kentucky Department for Environmental Protection Division of Waste ManagementHazardous Waste Branch300 Sower Blvd, Frankfort, KY 40601(502) 564-6716Registration Of Hazardous Waste Activity Addendum(EPA Form 8700-12)FOR OFFICIAL USE ONLY.DO NOT WRITE IN THIS SPACE.Fee Submitted: $ FORMTEXT ????? (Fill in amount enclosed – see instructions to determine your fee)I. Reason for Submittal(Mark all boxes that apply)Reason for Submittal: FORMCHECKBOX NEW – provide initial notification (to obtain an EPA ID Number for hazardous waste, universal waste, or used oil activities) FORMCHECKBOX RENEWAL – renew your EPA ID Number. Enter month your current certificate expires FORMTEXT ????? FORMCHECKBOX REACTIVATE AN EPA ID NUMBER FORMCHECKBOX MODIFICATION – provide subsequent notification or update site identification information.Mark all applicable modifications: FORMCHECKBOX Generator Status FORMCHECKBOX Contact Person FORMCHECKBOX Add/Delete Waste Streams FORMCHECKBOX Ownership FORMCHECKBOX Company Name FORMCHECKBOX Other (Explain) FORMTEXT ????? Enter previous owner and/or company name: FORMTEXT ????? II. Facility Name and Lat/LongFacility Name: FORMTEXT ????? Facility Latitude: FORMTEXT ????? Facility Longitude: FORMTEXT ?????III. ID NumbersA. EPA ID Number: KY FORMTEXT ?? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???B. AGENCY INTEREST (AI) Number: FORMTEXT ?????IV. Legal Landowner of the Real Property:Name of Landowner: FORMTEXT ?????Date Became Owner: (mm/dd/yyyy) FORMTEXT ? ?/ FORMTEXT ? ?/ FORMTEXT ? ???Landowner Type: FORMCHECKBOX Private FORMCHECKBOX Federal FORMCHECKBOX State FORMCHECKBOX Municipal FORMCHECKBOX County FORMCHECKBOX OtherPhone Number: FORMTEXT ?????Phone Number Extension: FORMTEXT ?????Street Address or P. O. Box: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Country: FORMTEXT ?????Zip Code: FORMTEXT ?????V. Type of Regulated Waste Activity Mark “X” in the appropriate boxes for waste activities not included in the EPA Form 8700. Complete any additional spaces as instructed.If Marked on EPA Form 8700 as a Transporter of Hazardous Waste, then mark “X” in all boxes that apply FORMCHECKBOX a. Transporter for Hire FORMCHECKBOX b. Transfer Facility FORMCHECKBOX c. Transport for SelfIf Marked on EPA Form 8700 as a Recycler of Hazardous Waste, then mark “X” in all boxes that apply FORMCHECKBOX a. Recycler of Lead Acid Batteries FORMCHECKBOX b. Recycler of Precious Metals FORMCHECKBOX c. Other Recycler Specify FORMTEXT ?????If Marked on EPA Form 8700 as an Off-Specification Used Oil Burner, then mark “X” in all boxes that apply FORMCHECKBOX a. Utility Boiler FORMCHECKBOX b. Industrial Boiler FORMCHECKBOX c. Industrial Furnace FORMCHECKBOX Used Oil Collection Centera. Storage capacity of facility:gallons FORMCHECKBOX Laboratory Conducting Treatability Studies FORMCHECKBOX Used Oil RecyclerAmount recycled in previous calendar year: gallons FORMCHECKBOX E-Scrap Collection Center FORMCHECKBOX Publicly Owned Treatment Works (POTW) Receiving Hazardous Waste FORMCHECKBOX Household Collection FORMCHECKBOX Other (describe): FORMTEXT ????? FORMCHECKBOX Generator Treating Hazardous Waste On-Site*Provide a brief description: FORMTEXT ?????*Additional Application Requirements for Treatment On-Site Activities – see instructionsPage 1 of FORMTEXT ?????EPA ID Number: KY FORMTEXT ?? FORMTEXT ???? FORMTEXT ???? FORMTEXT ??? Agency Interest Number: FORMTEXT ?????VI. Description of Current Hazardous WastesComplete one line per waste stream. Use additional pages as necessary.NOTE: For modifications, all current waste streams must be listed in addition to any new ones.Description of WasteEPA Waste Number(s)Physical StateMaximum Amount of Waste Generated in a Calendar MonthEstimated Annual Quantity of Waste GeneratedUnit of MeasureExample: paint related waste materialD001D035L5001,500PA. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????B. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????C. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????D. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????E. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????F. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????G. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????H. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????I. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????J. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL FOR ALL WASTE STREAMS FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????VII. Waste Streams Being DeletedRefer to your previous registration and list any waste streams this facility is no longer generating.This section is NOT APPLICABLE to first time applicants.Description of WasteEPA Waste Number(s)Description of WasteEPA Waste Number(s)A. FORMTEXT ????? FORMTEXT ?????D. FORMTEXT ????? FORMTEXT ?????B. FORMTEXT ????? FORMTEXT ?????E. FORMTEXT ????? FORMTEXT ?????C. FORMTEXT ????? FORMTEXT ?????F. FORMTEXT ?????????? FORMTEXT ??????????VIII. 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