ICR Appendix D-1: EPA Form 7710-53

United States
Environmental Protection Agency
Washington, DC 20460

USEPA

Form Approved
OMB No. 2070-0112

Notification of PCB Activity
For Official Use Only
Return To:
Fibers & Organics Branch (7404T)
Office of Pollution Prevention & Toxics
U.S. Environmental Protection Agency
1200 Pennsylvania Ave., N.W.
Washington, DC 20460-0001
1. Name of Facility

Name of Owner Facility

2. EPA Identification Number (if already assigned under RCRA)

3. Facility Mailing Address (Street or PO Box, City, State, & Zip Code) 4. Location of Facility (No. Street, City, State, & Zip Code)

5. Installation Contact (Name and Title)

Telephone Number (Area Code and Number)

6. Type of PCB Activity (Mark ‘X’ in appropriate box. See Instructions.)
A. Generator w/onsite storage facility

B. Storer (Commercial)

C. Transporter

D. R&D/Treatability

E. Approved Disposer

F. Scrap Metal Recovery Oven/Smelter,
High Efficiency Boilers

7. Certification

Under civil and criminal penalties of law for the making or submission of false or fraudulent statements
or representations (18 U.S.C. 1001 and 15 U.S.C. 2615), I certify that the information contained in or
accompanying this document is true, accurate, and complete. As to the identified section(s) of this
document for which I cannot personally verify truth and accuracy, I certify as a company official having
supervisory responsibility for the persons who, acting under my direct instructions, made the verification
that this information is true, accurate, and complete.
Signature

Name and Official Title (Type of Print)

Date Signed

Paperwork Reduction Act Notice

The annual public burden for this collection of information is estimated to average 0.57 hours per
response. This estimate includes time for reading instructions, searching existing data sources,
gathering and maintaining the needed data, and completing and re viewing collection of information.
Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden to: Director, Collection Strategies Division,
U.S. Environmental Protection Agency (mail code 2822), 1200 Pennsylvania Ave., N.W.,
Washington, D.C. 20460-0001. Include the OMB number identified above in any correspondence.
Do not send the completed form to this address. The actual information or form should be submitted in
accordance with the instructions accompanying the form, or as specified in the corresponding regulations.
EPA Form 7710-53 (Rev.6/02)
Previous editions are obsolete.