7720-121 PCB Transformer Registration

USEPA

United States
Environmental Protection Agency
Washington, DC 20460

Form Approved OMB No. 2070-0112
Expires 11/30/2022

PCB TRANSFORMER REGISTRATION
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. Company Name

Address

Contact Name & Phone #

2. a. Location of PCB Transformer(s) - Location #1

2. a. Location of PCB Transformer(s) - Location #2

b. No. of Transformers and wt. (kg):

b. No. of Transformers and wt. (kg):

c. Any transformers containing flammable dielectric fluid: Yes or No

c. Any transformers containing flammable dielectric fluid: Yes or No

2. a. Location of PCB Transformer(s) - Location #3

2. a. Location of PCB Transformer(s) - Location #4

b. No. of Transformers and wt. (kg):

b. No. of Transformers and wt. (kg):

c. Any transformers containing flammable dielectric fluid: Yes or No

c. Any transformers containing flammable dielectric fluid: Yes or No

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)

Paperwork Reduction Act Notice

Date Signed

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et
seq. (OMB Control No. 2070-0112). Responses to this collection of information are mandatory (40 CFR
761). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The public reporting and
recordkeeping burden for this collection of information is estimated to .57 hours per response. Send
comments on the Agency’s need for this information, the accuracy of the provided burden estimates and
any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S.
Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form 7720-12 (06/02)