8700-12; 8700-13 A RCRA Subtitle C Site Identification Form

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

United States Environmental Protection Agency RCRA SUBTITLE C SITE IDENTIFICATION FORM

Street Address
City, Town, or Village		County
State	Country	Zip Code

2. Site EPA ID Number

	Obtaining or updating an EPA ID number for an on-going regulated activity that will continue for a period of time. (Includes HSM activity)
	Submitting as a component of the Hazardous Waste Report for __________ (Reporting Year)
		Site was a TSD facility and/or generator of > 1,000 kg of hazardous waste, > 1 kg of acute hazardous waste, or > 100 kg of acute hazardous waste spill cleanup in one or more months of the reporting year (or State equivalent LQG regulations)
	Notifying that regulated activity is no longer occurring at this Site
	Obtaining or updating an EPA ID number for conducting Electronic Manifest Broker activities
	Submitting a new or revised Part A Form

1. Reason for Submittal (Select only one.)

7. North American Industry Classification System (NAICS) Code(s) for the Site (at least 5-digit codes)

3. Site Name

4. Site Location Address

6. Site Land Type

A. (Primary)	C.
B.	D.

5. Site Mailing Address

OMB # 2050-0024 Expires

Street Address
City, Town, or Village
State	Country	Zip Code

 Same as Location Address

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

First Name	MI	Last Name
Title
Street Address
City, Town, or Village
State	Country	Zip Code
Email
Phone	Ext	Fax

8. Site Contact Information

Owner Type  Private  County  District  Federal  Tribal  Municipal  State  Other
Street Address
City, Town, or Village
State	Country	Zip Code
Email
Phone	Ext	Fax
Comments

9. Legal Owner and Operator of the Site

A. Name of Site’s Legal Owner

B. Name of Site’s Legal Operator

EPA ID Number

OMB# 2050-0024 Expires __

Full Name

Date Became Operator (mm/dd/yyyy)

Operator Type  Private  County  District  Federal  Tribal  Municipal  State  Other
Street Address
City, Town, or Village
State	Country	Zip Code
Email
Phone	Ext	Fax
Comments

 Same as Location Address

 Same as Location Address

 Same as Location Address

Full Name

Date Became Owner (mm/dd/yyyy)

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

10. Type of Regulated Waste Activity (at your site)

Mark “Yes” or “No” for all current activities (as of the date submitting the form); complete any additional boxes as instructed.

A. Hazardous Waste Activities

 Y  N

1. Generator of Hazardous Waste—If “Yes”, mark only one of the following—a, b, c

		a. LQG	-Generates, in any calendar month (includes quantities imported by importer site) 1,000 kg/mo (2,200 lb/mo) or more of non-acute hazardous waste; or - Generates, in any calendar month, or accumulates at any time, more than 1 kg/mo (2.2 lb/mo) of acute hazardous waste; or - Generates, in any calendar month or accumulates at any time, more than 100 kg/mo (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.
		c. VSQG	Less than or equal to 100 kg/mo (220 lb/mo) of non-acute hazardous waste.

 Y  N

2. Short-Term Generator (generates from a short-term or one-time event and not from on-going processes). If “Yes”, provide an explanation in the Comments section.

 Y  N

3. Mixed Waste (hazardous and radioactive) Generator

 Y  N

4. Treater, Storer or Disposer of Hazardous Waste—Note: A hazardous waste Part B permit is required for these activities.

 Y  N

6. Recycler of Hazardous Waste

		a. Recycler who stores prior to recycling
		b. Recycler who does not store prior to recycling

 Y  N

7. Exempt Boiler and/or Industrial Furnace—If “Yes”, mark all that apply.

		a. Small Quantity On-site Burner Exemption
		b. Smelting, Melting, and Refining Furnace Exemption

 Y  N

5. Receives Hazardous Waste from Off-site

EPA ID Number

OMB# 2050-0024 Expires __

B. Waste Codes for Federally Regulated Hazardous Wastes. Please list the waste codes of the Federal hazardous wastes handled at your site. List them in the order they are presented in the regulations (e.g. D001, D003, F007, U112). Use an additional page if more spaces are needed.

C. Waste Codes for State Regulated (non-Federal) Hazardous Wastes. Please list the waste codes of the State hazardous wastes handled at your site. List them in the order they are presented in the regulations. Use an additional page if more spaces are needed.

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

 Y  N

2. Underground Injection Control

 Y  N

4. Recognized Trader—If “Yes”, mark all that apply.

		a. Importer
		b. Exporter

 Y  N

5. Importer/Exporter of Spent Lead-Acid Batteries (SLABs) under 40 CFR 266 Subpart G—If “Yes”, mark all that apply.

		a. Importer
		b. Exporter

EPA ID Number

OMB# 2050-0024 Expires __

Additional Regulated Waste Activities (NOTE: Refer to your State regulations to determine if a separate permit is required.)

B. Universal Waste Activities

 Y  N

1. Large Quantity Handler of Universal Waste (you accumulate 5,000 kg or more) - If “Yes” mark all that apply. Note: Refer to your State regulations to determine what is regulated.

		a. Batteries
		b. Pesticides
		c. Mercury containing equipment
		d. Lamps
		e. Other (specify) ______________________________________________
		f. Other (specify) ______________________________________________
		g. Other (specify) ______________________________________________

 Y  N

Destination Facility for Universal Waste Note: A hazardous waste permit may be required for this activity.

C. Used Oil Activities

 Y  N

1. Used Oil Transporter—If “Yes”, mark all that apply.

		a. Transporter
		b. Transfer Facility (at your site)

 Y  N

2. Used Oil Processor and/or Re-refiner—If “Yes”, mark all that apply.

		a. Processor
		b. Re-refiner

 Y  N

3. Off-Specification Used Oil Burner

 Y  N

4. Used Oil Fuel Marketer—If “Yes”, mark all that apply.

		a. Marketer Who Directs Shipment of Off-Specification Used Oil to Off-Specification Used Oil Burner
		b. Marketer Who First Claims the Used Oil Meets the Specifications

A. Other Waste Activities

 Y  N

3. United States Importer of Hazardous Waste

 Y  N

1. Transporter of Hazardous Waste—If “Yes”, mark all that apply.

		a. Transporter
		b. Transfer Facility (at your site)

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

12. Eligible Academic Entities with Laboratories—Notification for opting into or withdrawing from managing laboratory hazardous wastes pursuant to 40 CFR 262 Subpart K.

 Y  N

A. Opting into or currently operating under 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories—If “Yes”, mark all that apply. Note: See the item-by-item instructions for definitions of types of eligible academic entities.

		1. College or University
		2. Teaching Hospital that is owned by or has a formal written affiliation with a college or university
		3. Non-profit Institute that is owned by or has a formal written affiliation with a college or university

 Y  N

B. Withdrawing from 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories.

EPA ID Number

OMB# 2050-0024 Expires __

16. Notification of Hazardous Secondary Material (HSM) Activity

 Y  N

A. Are you notifying under 40 CFR 260.42 that you will begin managing, are managing, or will stop managing hazardous secondary material under 40 CFR 260.30, 40 CFR 261.4(a)(23), (24), or (27)? If “Yes”, you must fill out the Addendum to the Site Identification Form for Managing Hazardous Secondary Material.

 Y  N

B. Are you notifying under 40 CFR 260.43(a)(4)(iii) that the product of your recycling process has levels of hazardous constituents that are not comparable to or unable to be compared to a legitimate product or intermediate but that the recycling is still legitimate? If “Yes”, you may provide explanation in Comments section. You must also document that your recycling is still legitimate and maintain that documentation on site.

17. Electronic Manifest Broker

 Y  N

Are you notifying as a person, as defined in 40 CFR 260.10, electing to use the EPA electronic manifest system to obtain, complete, and transmit an electronic manifest under a contractual relationship with a hazardous waste generator?

 Y  N

Are you an LQG notifying of consolidating VSQG Hazardous Waste Under the Control of the Same Person pursuant to 40 CFR 262.17(f)? If “Yes”, you must fill out the Addendum for LQG Consolidation of VSQGs hazardous waste.

 Y  N

LQG Site Closure of a Central Accumulation Area (CAA) or Entire Facility.

	1.  Central Accumulation Area (CAA) or  Entire Facility
	2. Expected closure date: ____________ mm/dd/yyyy
	3. Requesting new closure date: ____________ mm/dd/yyyy
	4. Date closed : ____________ mm/dd/yyyy  a. In compliance with the closure performance standards 40 CFR 262.17(a)(8)  b. Not in compliance with the closure performance standards 40 CFR 262.17(a)(8)

14. LQG Consolidation of VSQG Hazardous Waste

15. Notification of LQG Site Closure for a Central Accumulation Area (CAA) (optional) OR Entire Facility (required)

 Y  N

Are you an SQG or VSQG generating hazardous waste from a planned or unplanned episodic event, lasting no more than 60 days, that moves you to a higher generator category. If “Yes”, you must fill out the Addendum for Episodic Generator.

13. Episodic Generation

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

EPA ID Number

OMB# 2050-0024 Expires __

18. Comments (include item number for each comment)

19. Certification I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. Note: For the RCRA Hazardous Waste Part A permit Application, all owners and operators must sign (see 40 CFR 270.10(b) and 270.11).

Signature of legal owner, operator or authorized representative	Date (mm/dd/yyyy)
Printed Name (First, Middle Initial Last)	Title
Email

Signature of legal owner, operator or authorized representative	Date (mm/dd/yyyy)
Printed Name (First, Middle Initial Last)	Title
Email

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

ADDENDUM TO THE SITE IDENTIFICATION FORM: NOTIFICATION OF HAZARDOUS SECONDARY MATERIAL ACTIVITY

ONLY fill out this form if:

You are located in a State that allows you to manage excluded hazardous secondary material (HSM) under 40 CFR 261.2(30), 261.4(a)(23), (24), or (27) (or state equivalent; See https://www.epa.gov/epawaste/hazard/dsw/statespf.htm 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), or (27) (or state equivalent) or have stopped managing excluded HSM in compliance with the exclusion(s) and do not expect to manage any amount of excluded HSM under the exclusion(s) for at least one year. Do not include any information regarding your hazardous waste activities in this section. Note: If your facility was granted a solid waste variance under 40 CFR 260.30 prior to July 13, 2015, your management of HSM under 40 CFR 260.30 is grandfathered under the previous regulations and you are not required to notify for the HSM management activity excluded under 40 CFR 260.30.

1. Reason for Notification (Include dates where requested)

 Facility will begin managing excluded HSM as of _______________ (mm/dd/yyyy).

 Facility is still managing excluded HSM/re-notifying as required by March 1 of each even-numbered year.

 Facility has stopped managing excluded HSM as of _______________ (mm/dd/yyyy) and is notifying as required.

2. Description of Excluded HSM Activity. Please list the appropriate codes (see Code List section of the instructions) and quantities, in short tons, to describe your excluded HSM activity ONLY (do not include any information regarding your hazardous wastes). Use additional pages if more space is needed.

A. Facility Code	B. Waste Code(s) for HSM	C. Estimate Short Tons of excluded HSM to be managed annually	D. Actual Short Tons of excluded HSM that was managed during the most recent odd-numbered year	E. Land-based Unit Code

EPA ID Number

OMB# 2050-0024 Expires __

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

ADDENDUM TO THE SITE IDENTIFICATION FORM: EPISODIC GENERATOR

ONLY fill out this form if:

You are an SQG or VSQG generating hazardous waste from a planned or unplanned episodic event, lasting no more then 60 days, that moves the generator to a higher generator category pursuant to 40 CFR Part 262 Subpart L. Note: Only one planned and one unplanned episodic event are allowed within one year; otherwise, you must follow the requirements of the higher generator category. Use additional pages if more space is needed.

Episodic Event
Planned  Excess chemical inventory removal  Tank cleanouts  Short-term construction or demolition  Equipment maintenance during plant shutdowns  Other ________________________________________		B. Unplanned  Accidental spills  Production process upsets  Product recalls  “Acts of nature” (Tornado, hurricane, flood, etc.)  Other ________________________________________
C. Emergency Contact Phone	D. Emergency Contact Name
E. Beginning Date _______________ (mm/dd/yyyy)		F. End Date _______________ (mm/dd/yyyy)

EPA ID Number

OMB# 2050-0024 Expires __

G. Waste Description				H. Estimated Quantity (in pounds)
I. Federal and/or State Hazardous Waste Codes

Waste 1

G. Waste Description				H. Estimated Quantity (in pounds)
I. Federal and/or State Hazardous Waste Codes

Waste 2

G. Waste Description				H. Estimated Quantity (in pounds)
I. Federal and/or State Hazardous Waste Codes

Waste 3

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

ADDENDUM TO THE SITE IDENTIFICATION FORM: LQG CONSOLIDATION OF VSQG HAZARDOUS WASTE

ONLY fill out this form if:

You are an LQG receiving hazardous waste from VSQGs under the control of the same person. Use additional pages if more space is needed.

VSQG 1
A. EPA ID Number (if assigned)	B. Name
C. Street Address
D. City, Town, or Village	E. State	F. Zip Code
G. Contact Phone Number	H. Contact Name
I. Email

EPA ID Number

OMB# 2050-0024 Expires __

VSQG 2
A. EPA ID Number (if assigned)	B. Name
C. Street Address
D. City, Town, or Village	E. State	F. Zip Code
G. Contact Phone Number	H. Contact Name
I. Email

VSQG 3
A. EPA ID Number (if assigned)	B. Name
C. Street Address
D. City, Town, or Village	E. State	F. Zip Code
G. Contact Phone Number	H. Contact Name
I. Email

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

EPA ID Number

OMB# 2050-0024 Expires __

United States Environmental Protection Agency HAZARDOUS WASTE REPORT ______ (reporting cycle) WASTE GENERATION AND MANAGEMENT (GM) FORM

1. Waste Characteristics

2. On-site Generation and Management of Hazardous Waste

 Y  N

Was any of this waste that was generated at this facility treated, disposed, and/or recycled on-site? If yes, continue to On-site Process System 1.

3. Off-site Shipment of Hazardous Waste

 Y  N

A. Was any of this waste that was generated at this facility shipped off-site for treatment, disposal, or recycling? If yes, continue to Site 1.

4. Comments

B. EPA Hazardous Waste Code(s)
C. State Hazardous Waste Code(s)

Site 1
B. EPA ID of facility to which waste was shipped	C. Management Method Code	D. Total Quantity Shipped

Process System 1

Management Method Code

Quantity

Process System 2

Management Method Code

Quantity

D. Source Code	Management Method Code (for Source Code G25 only)	E. Form Code

F. Quantity Generated	UOM	Density		G. Waste minimization code
			 lbs/gal  sg

Site 1
B. EPA ID of facility to which waste was shipped	C. Management Method Code	D. Total Quantity Shipped

Site 1
B. EPA ID of facility to which waste was shipped	C. Management Method Code	D. Total Quantity Shipped

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

EPA ID Number

OMB# 2050-0024 Expires __

United States Environmental Protection Agency HAZARDOUS WASTE REPORT ______ (reporting year) WASTE RECEIVED FROM OFF-SITE (WR) FORM

4. Comments

1. Waste 1

B. EPA Hazardous Waste Code(s)
C. State Hazardous Waste Code(s)

D.Off-site EPA ID Number	E. Quantity Received	UOM	Density
				 lbs/gal  sg
F. Form Code		G. Management Method Code

2. Waste 2

B. EPA Hazardous Waste Code(s)
C. State Hazardous Waste Code(s)

D.Off-site EPA ID Number	E. Quantity Received	UOM	Density
				 lbs/gal  sg
F. Form Code		G. Management Method Code

3. Waste 3

B. EPA Hazardous Waste Code(s)
C. State Hazardous Waste Code(s)

D.Off-site EPA ID Number	E. Quantity Received	UOM	Density
				 lbs/gal  sg
F. Form Code		G. Management Method Code

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

EPA ID Number

OMB# 2050-0024 Expires __

United States Environmental Protection Agency 2017 HAZARDOUS WASTE REPORT OFF-SITE IDENTIFICATION (OI) FORM

1. Site 1

A. EPA ID Number of Off-site Installation or Transporter

B. Name of Off-site Installation or Transporter

C. Handler Type (mark all that apply)  Generator  Transporter  Receiving Facility

4. Comments

Address of Off-site Installation Street Address
City, Town, or Village
State	Zip Code

2. Site 2

A. EPA ID Number of Off-site Installation or Transporter

B. Name of Off-site Installation or Transporter

C. Handler Type (mark all that apply)  Generator  Transporter  Receiving Facility

Address of Off-site Installation Street Address
City, Town, or Village
State	Zip Code

3. Site 3

A. EPA ID Number of Off-site Installation or Transporter

B. Name of Off-site Installation or Transporter

C. Handler Type (mark all that apply)  Generator  Transporter  Receiving Facility

Address of Off-site Installation Street Address
City, Town, or Village
State	Zip Code

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

United States Environmental Protection Agency HAZARDOUS WASTE PERMIT PART A FORM

1. Facility Permit Contact

Street Address
City, Town, or Village
State	Country	Zip Code

2. Facility Permit Contact Mailing Address

First Name	MI	Last Name
Title
Email
Phone	Ext	Fax

3. Facility Existence Date (mm/dd/yyyy)

4. Other Environmental Permits

A. Permit Type

B. Permit Number

C. Description

5. Nature of Business

EPA ID Number

OMB# 2050-0024 Expires __

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page __ of __ _____

6. Process Codes and Design Capacities

Line Number		A. Process Code			B. Process Design Capacity		C. Process Total Number of Units	D. Unit Name
					(1) Amount	(2) Unit of Measure

EPA ID Number

OMB# 2050-0024 Expires __

Line No.

A. EPA Hazardous Waste No.

B. Estimated Annual Qty of Waste

C. Unit of Measure

D. Processes

(1) Process Codes

Process Description (if code is not entered in 7.D1))

7. Description of Hazardous Wastes (Enter codes for Items 7.A, 7.C and 7.D(1) )

8. Map

Attach to this application a topographical map, or other equivalent map, of the area extending to at least one mile beyond property boundaries. The map must show the outline of the facility, the location of each of its existing intake and discharge structures, each of its hazardous waste treatment, storage, or disposal facilities, and each well where it injects fluids underground. Include all spring, rivers, and other surface water bodies in this map area. See instructions for precise requirements.

9. Facility Drawing

All existing facilities must include a scale drawing of the facility. See instructions for more detail.

10. Photographs

All existing facilities must include photographs (aerial or ground-level) that clearly delineate all existing structures; existing storage, treatment, and disposal areas; and sites of future storage, treatment, or disposal areas. See instructions for more detail.

11. Comments