6200-025 PCB Annual Report

OMB Control Number: 2050-NEW Expiration Date: tbd

United States Environmental Protection Agency

PCB ANNUAL REPORT FORM

40 CFR 761.180(b)(3)

EPA Form # 6200-025

1. Submitter Information

Name: ____________________________	Job Title: _________________________
Phone Number: ____________________	Email Address: ____________________

2. Facility EPA ID Number

EPA ID Number: _______________________

3. Facility Name and Address

Facility Name: _________________________________________________________
Street Address: ________________________________________________________
City: _____________________	State: __________	Zip Code: ______________

4. Reporting Calendar Year

Calendar Year: _____________

5. Facility Type

Commercial Storer

Disposer

Both

6. Technology Type (check all

that apply)

	Incinerator		Chemical Dechlorination
	Chemical Waste Landfill		High Efficiency Boiler
	Scrap Metal Recovery Oven		Fluorescent Light Ballast Recycler
	PCB Electrical Cable Processing for Metal Recovery		PCB Transformer Decommissioning
	Pipeline and Compressor Systems Decontamination		Other ____________________

7. PCB Waste in Storage at the Beginning of the Calendar Year

	Large Low and High Voltage Capacitors	Article Containers	Transformers	Bulk	Containers	Other
Weight (kg)
Total Number				N/A

8. PCB Waste Received and Generated During the Calendar Year

(1)	Large Low and High Voltage Capacitors		Article Containers		Transformers
	Received	Generated	Received	Generated	Received	Generated
Weight (kg)
Total Number

8. PCB Waste Received and Generated During the Calendar Year

(2)	Bulk		Containers		Other
	Received	Generated	Received	Generated	Received	Generated
Weight (kg)
Total Number	N/A	N/A

9. PCB Waste Transferred to Another Facility During the Calendar Year

	Large Low and High Voltage Capacitors	Article Containers	Transformers	Bulk	Containers	Other
Weight (kg)
Total Number				N/A

10. PCB Waste Disposed of at the Facility During the Calendar Year

	Large Low and High Voltage Capacitors	Article Containers	Transformers	Bulk	Containers	Other
Weight (kg)
Total Number				N/A

11. PCB Waste in Storage at the Facility at the end of the Calendar Year

	Large Low and High Voltage Capacitors	Article Containers	Transformers	Bulk	Containers	Other
Weight (kg)
Total Number				N/A

12. Number of Manifests Sent/Received

Number of Incoming Manifests:	_______________
Number of Outgoing Manifests:	_______________
Total Number of Manifests:	_______________

Paperwork Reduction Act Notice

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control Number: 2050-NEW). Responses to this collection of information are mandatory under 40 CFR 761.180(b)(3). 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 be 7.6 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 Branch 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.

INSTRUCTIONS FOR FILLING OUT THE PCB ANNUAL REPORT FORM

______________________________________________________________________________

Who Must Use this Form

Owners or operators of facilities who dispose of or commercially store PCB waste are required to submit a PCB Annual Report for that calendar year (40 CFR 761.180(b)(3)). Owners or operators of facilities who dispose of or commercially store PCB waste are required to use this form to submit the information.

Purpose of this Form

This form is made available to ease the PCB Annual Report process for owners and operators of

facilities who dispose of or commercially store PCB waste. Such facilities are required to submit information on PCB waste in storage at the beginning of the calendar year, received, generated,

transferred, and disposed during the calendar year, and in storage at the end of the calendar year.

For more information on the reporting requirements, please refer to 40 CFR 761.180.

Where to Send this Form

Owners or operators of facilities who dispose of or commercially store PCB waste should print the completed form, and any applicable attachments, and mail or email it to the address listed below.

Document Control Officer

Office of Resource Conservation and Recovery

U.S. Environmental Protection Agency

1200 Pennsylvania Ave., N.W. MC 5303T

Washington, D.C., 20460-0001

OR

[email protected]

How to Fill out this Form

Please pay attention to the following notes when completing this form:

• Please fill out all sections of the form, even if they are not applicable to your facility. For example, if your facility did not dispose of any PCB waste, enter “0” for all items in section number 10 instead of leaving those fields blank. Please note that negative values are not valid.

• Enter both received and generated values for Item 8, not one combined value.

• Refer to Attachment A for definitions of PCB waste categories.

If you have any questions regarding this form, please contact your EPA Regional Coordinator or EPA Headquarters. https://www.epa.gov/pcbs/program-contacts.

ATTACHMENT A

Select Definitions of PCB Waste

______________________________________________________________________________

Large high voltage capacitor means a capacitor which contains 1.36 kg (3 lbs.) or more of dielectric fluid and which operates at 2,000 volts (AC or DC.) or above.

Large low voltage capacitor means a capacitor which contains 1.36 kg (3 lbs.) or more of dielectric fluid and which operates below 2,000 volts (AC or DC).

PCB Article Container means any package, can, bottle, bag, barrel, drum, tank, or other device used to contain PCB Articles or PCB Equipment, and whose surface(s) has not been in direct contact with PCBs.

PCB Article means any manufactured article, other than a PCB Container, that contains PCBs and whose surface(s) has been in direct contact with PCBs. “PCB Article” includes capacitors, transformers, electric motors, pumps, pipes and any other manufactured item (1) which is formed to a specific shape or design during manufacture, (2) which has end use function(s) dependent in whole or in part upon its shape or design during end use, and (3) which has either no change of chemical composition during its end use or only those changes of composition which have no commercial purpose separate from that of the PCB Article.

PCB Equipment means any manufactured item, other than a PCB Container or a PCB Article Container, which contains a PCB Article or other PCB Equipment, and includes microwave ovens, electronic equipment, and fluorescent light ballasts and fixtures.

PCB Transformer means any transformer that contains ≥500 ppm PCBs. For PCB concentration assumptions applicable to transformers containing 1.36 kilograms (3 lbs.) or more of fluid other than mineral oil, see § 761.2. For provisions permitting reclassification of electrical equipment, including PCB Transformers, containing ≥500 ppm PCBs to PCB-Contaminated Electrical Equipment, see § 761.30(a) and (h).

Bulk PCB Waste means waste that is classified as either PCB Remediation Waste or PCB Bulk Product Waste (see those definitions below).

PCB Bulk Product Waste means waste derived from manufactured products containing PCBs in a non-liquid state, at any concentration where the concentration at the time of designation for disposal was ≥50 ppm PCBs. PCB bulk product waste does not include PCBs or PCB Items regulated for disposal under §§ 761.60(a) through (c), 761.61, 761.63, or 761.64. PCB bulk product waste includes, but is not limited to:

1. Non-liquid bulk wastes or debris from the demolition of buildings and other manmade structures manufactured, coated, or serviced with PCBs. PCB bulk product waste does not include debris from the demolition of buildings or other man-made structures that is contaminated by spills from regulated PCBs which have not been disposed of, decontaminated, or otherwise cleaned up in accordance with subpart D of this part.

2. PCB-containing wastes from the shredding of automobiles, household appliances, or industrial appliances.

3. Plastics (such as plastic insulation from wire or cable; radio, television and computer casings; vehicle parts; or furniture laminates); preformed or molded rubber parts and components; applied dried paints, varnishes, waxes or other similar coatings or sealants; caulking; adhesives; paper; Galbestos; sound deadening or other types of insulation; and felt or fabric products such as gaskets.

4. Fluorescent light ballasts containing PCBs in the potting material.

PCB Container means any package, can, bottle, bag, barrel, drum, tank, or other device that contains PCBs or PCB Articles and whose surface(s) has been in direct contact with PCBs.

PCB Remediation Waste means waste containing PCBs as a result of a spill, release, or other unauthorized disposal, at the following concentrations:

• Materials disposed of prior to April 18, 1978, that are currently at concentrations ≥ 50 ppm PCBs, regardless of the concentration of the original spill;

• Materials which are currently at any volume or concentration where the original source was ≥ 500 ppm PCBs beginning on April 18, 1978, or ≥ 50 ppm PCBs beginning on July 2, 1979; and

• Materials which are currently at any concentration if the PCBs are spilled or released from a source not authorized for use under this part.

PCB remediation waste means soil, rags, and other debris generated as a result of any PCB spill cleanup, including, but not limited to:

1. Environmental media containing PCBs, such as soil and gravel; dredged materials, such as sediments, settled sediment fines, and aqueous decantate from sediment.

2. Sewage sludge containing < 50 ppm PCBs and not in use according to § 761.20(a)(4); PCB sewage sludge; commercial or industrial sludge contaminated as the result of a spill of PCBs including sludges located in or removed from any pollution control device; aqueous decantate from an industrial sludge.

3. Buildings and other man-made structures (such as concrete floors, wood floors, or walls contaminated from a leaking PCB or PCB-Contaminated Transformer), porous surfaces, and non-porous surfaces.

Other Waste Category should be utilized for wastes that cannot be classified as: Large Low or High Voltage Capacitor, Article Container, Transformer, Bulk waste, or Container. Examples of “Other” waste includes small capacitors, circuit breakers, PCB-contaminated transformers (<500 ppm), and pipeline.

EPA Form 6200-025 Page 6 of 6