### EPA ID: |__|__|__|__|__|__|__|__|__|__|__|__|

SEND

COMPLETED

FORM TO:

KDHE-BWM

1000 SW Jackson

Suite 320

Topeka, KS

66612 

## Kansas Department of Health and Environment

Notification of Regulated Waste Activity

(RCRA SUBTITLE C SITE IDENTIFICATION FORM)

FORMS 8700-12 and 8700-23

1. Reason for

Submittal

MARK ALL

BOXES

THAT

APPLY Reason for Submittal:

To provide Initial Notification of Regulated Waste Activity (to obtain an EPA ID Number for hazardous waste, or used oil

activities)

To provide Subsequent Notification of Regulated W aste Activity (to update site identification inform ation)

As a component of a First RCRA Hazardous Waste Pa rt A Permit Application

As a component of a Revised RCRA Hazardous Waste Part A Permit Application (Amendment # )

As a component of the Hazardous Waste Report

Site was a TSD facility and/or generator of >1,00 0 kg of hazardous waste, >1 kg of acute hazardous w aste, or >100 kg of

acute hazardous waste spill cleanup in one or more months of the report year.

2. Site EPA ID

Number EPA ID Number 

## |__|__|__| |__|__|__| |__|__|__| |__|__|__|

3. Site Name Name:

4. Site Location Street Address:

City, Town, or Village: County:

State: Country: Zip Code:

5. Site Land

Type Private County District Federal Tribal Municipal State Other

6. NAICS

Code(s)

(5 or more digits) A. B. C. D.

7. Site Mailing

Address Street or P.O. Box:

City, Town, or Village:

State: Country: Zip Code:

8. Site Contact

Person First Name: MI: Last:

Title:

Street or PO Box:

City, Town or Village:

State: Country: Zip Code:

Email:

Phone: Ext: Fax:

9. Legal Owner

and Operator

of the Site A. Name of Site’s Legal Owner: Date Became Owner:

(mm/dd/yyyy)

Owner Type: Private County District Federal Tribal Municipal State Other

Street or PO Box:

City, Town or Village: Phone:

State: Country: Zip Code:

B: Name of Site’s Operator: Date Became Operator:

(mm/dd/yyyy)

Operator Type: Private County District Federal Tribal Municipal State Other

### EPA ID: |__|__|__|__|__|__|__|__|__|__|__|__|

10. Type of Regulated Waste Activity

Mark “Y” (yes) or “N” (no) for all activ ities; complete any additional boxes as instructed. (See pages 4 to 7 of instructions.)

A. Hazardous Waste Activities

Complete all parts 1 through 10.

Y N 1. Generator of Hazardous Waste

If “Yes”, choose only one of t he following:

a. LQG: Greater than 1,000 kg/mo (2,200 lbs/mo) of

non-acute hazardous waste; or generates more than

1 kg (2.2 lbs) of acutely hazardous waste

b. SQG: 100 to 1,000 kg/mo (220-2,200 lbs/mo) of

non-acute hazardous waste; or accumulates less than

1 kg (2.2 lbs) of acutely hazardous waste

c. KSQG: 25 to less than 100 kg/mo (55-220 lbs/mo )

of non-acute hazardous waste; or accumulates less

than 1 kg (2.2 lbs) of acutely hazardous waste

d. CESQG: Less than 25 kg/mo (55lbs/mo) of nonacute hazardous waste

In addition, indicate other generator activities.

Y N 2. Short-Term Generator (generate from a short-term or

one-time event and not from an on-going processes.

If Yes, provide info under Comments Section.

Y N 3. United States Importer of Hazardous Waste

Y N 4. Mixed Waste (hazardous & radioactive) Generator Y N 5. Transporter of Hazardous Waste.

If “Yes”, mark all that apply.

a. Transporter

b. Transfer Facility (at your site)

Y N 6. Treater, Storer, or Disposer of Hazardous Was te (at your

site)

Note: A hazardous waste permit is required for this activity.

Y N 7. Recycler of Hazardous Waste (at your site)

Note: A permit may be required.

Y N 8. Exempt Boiler and/or industrial Furnace

If “Yes”, mark each that applie s.

a. Small Quantity On-site Burner Exemption

b. Smelting, Melting, and Refining Furnace Exempt ion

Y N 9. Underground Injection Control

Y N 10. Receives Hazardous Waste from Off-Site

B. Universal Waste Activities; Complete all parts 1-2:

Y N 1. Large Quantity Handler of Universal Waste

(You accumulate 5,000 kg or more. Refer to Kansas

regulations to determine what is regulated.) Indic ate the

types of universal waste generated and/or accumulat ed at

your site.

Mark all boxes that apply.

a. Batteries

b. Pesticides

c. Mercury containing equipment

d. Lamps

e. Others (Describe in Item 12 – Comments)

Y N 2. Destination Facility for Universal Waste.

Note: A hazardous waste permit may be required for

this activity. C. Used Oil Activities

Mark all boxes that apply.

Y N 1. Used Oil Transporter

If “Yes”, mark each that applie s.

a. Transporter

b. Transfer Facility

Y N 2. Used Oil Processor and/or Re-refiner

If “Yes”, mark each that applie s.

a. Processor

b. Re-refiner

Y N 3. Off-Specification Used Oil Burner

Y N 4. Used Oil Fuel Marketer

If “Yes”, mark each that applie s.

a. Marketer Who Directs Shipment of Off-Specificat ion

Used Oil to Off-Specification Used Oil Burner

b. Marketer Who First Claims the Used Oil Meets t he

Specifications

### EPA ID: |__|__|__|__|__|__|__|__|__|__|__|__|

11. Description of Hazardous Wastes

A. Waste Codes for Federally Regulated Hazardous W astes. Please list the waste codes of the Federal hazardou s wastes handled at your site.

List them in the order they are presented in the re gulations (e.g., D001, D003, F007, U112). Use an a dditional page if more spaces are needed.

12. Comments

13. Certification. I certify under penalty of law that this document a nd all attachments were prepared under my direction or supervision in

accordance with a system designed to assure that qu alified 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 th e information, the information, submitted is,

to be the best of my knowledge and belief, true acc urate, and complete. I am aware that there are sig nificant penalties for submitting false

information, including the possibility of fine and imprisonment for knowing violations.

Signature of operator, owner, or an

authorized representative Name and Official Title (type or print) Date Signed

(mm/dd/yyyy)Revised 6/14/2013 

### 1 

# Instructions for Completing

Notification of Regulated Waste Activity Form

(RCRA Subtitle C Site Identification Form)

Forms KDHE 8700-12 and 8700-23

INITIAL NOTIFICATIONS

If you do not currently have an EPA (Environmental Protection Agency) Identification (ID) Number and

you conduct a regulated waste activity at your site , you must submit an initial notification to obtain an

EPA ID Number. An initial notification must be sub mitted if you conduct one or more of the following

activities at your site:

1. If you generate, transport, treat, store, or dis pose of regulated hazardous wastes;

2. If you recycle hazardous wastes. (Hazardous wast es that are recycled are called recyclable

materials). The recycling process itself is exempt from regulation, but you must notify the

Kansas Department of Health And Environment (KDHE) and obtain an EPA ID Number if you

manage hazardous wastes prior to recycling;

3. If you are a large quantity handler of universal waste;

4. If you transport, process, or re-refine used oil ; burn off-specification used oil for energy

recovery; or market used oil; or

5. If your business moves to another location and y ou are still conducting regulated waste activities.

If you have questions about any regulated waste act ivity, please call the KDHE Bureau of Waste

Management (BWM) at 785-296-1600. Additional infor mation, including this form and its instructions,

is also available on BWM’s website: http://www.kdheks.gov/waste



## SUBSEQUENT NOTIFICATIONS

Even if you have submitted an initial notification and have received an EPA ID Number, you may be

required to submit a subsequent notification. Kans as Administrative Regulations (K.A.R.) 28-31-4(c)

requires that anytime there is a change in the information used t o obtain the EPA ID Number, the

generator shall submit these changes to the KDHE, n o more than 60 days after the change occurs

. In general, you should submit a subsequent notifica tion under the following circumstances:

1. If your business moves to another location;

2. If your business name changes:

3. If your generator classification changes;

4. If the contact person for your site changes;

5. If the ownership of your site changes;

6. If an additional owner has been added or replace d since you submitted your initial notification;

or

7. If the type of regulated waste activity you cond uct changes.



## HOW TO FILL OUT THIS FORM

Please read and follow all instructions. Pay parti cular attention to information contained in the NOTE

boxes or information that is bolded and/or underlined. If you need assistance, please call the Bureau

of Waste Management at 785-296-1600.Revised 6/14/2013 

### 2 For subsequent notifications, write your site’s EPA ID Number in Item 2. Use the space for

Comments in Item 12 to clarify or provide additiona l information for any item. When entering

information in the Comments section, please identif y the item number and box letter to which the

comment refers. If you must use additional sheets, please write your site’s EPA ID Number on each

additional sheet provided.



## ITEM-BY-ITEM INSTRUCTIONS

Item 1 – Reason for Submittal:

Place an "X" in the appropriate box to indicate whe ther this form is your Initial Notification to obta in

an EPA ID Number or a Subsequent Notification to up date your site identification information.

• For Initial Notification of Regulated Waste Activit y to provide site identification information

and obtain an EPA ID Number for hazardous waste, un iversal waste, or used oil activities

. If

your waste activity is regulated under Subtitle C o f the Resource Conservation and Recovery Act

(RCRA) and the Kansas regulations enacted pursuant to RCRA, you must submit this form to notify

the KDHE of your regulated waste activities and obt ain an EPA ID Number.

• For Subsequent Notification of Regulated Waste Acti vity to update site identification

information. You must use this form to submit a subsequent notif ication if your site already has an

EPA ID Number and you need to update your original information (e.g., generator status, new

owner, new mailing address).

• As a component of the First RCRA Hazardous Waste Pa rt A Permit Application. If your site is

planning to treat, store, or dispose of hazardous w aste on site in a unit that is not exempt from

obtaining a hazardous waste permit, you must submit this form as part of the Part A Permit

Application. Also, if the activity at this site (t reatment, storage, or disposal) became newly regula ted

under RCRA Subtitle C (specifically 40 CFR Parts 26 0-299), you must submit this form as part of

the Part A Permit Application.

• As a component of a Revised RCRA Hazardous Waste Pa rt A Permit Application. If you must

submit a revised Part A Permit Application to refle ct changes that have occurred at your site, you

must submit this form as part of your revised Part A Permit Application. Examples of site changes

requiring a revised Part A Permit Application inclu de managing new wastes not identified in the first

submission of the form or changes to existing waste treatment processes. When submitting a revised

Part A Permit Application, please include the Amend ment number in the appropriate space.

• As a component of the Hazardous Waste Report. If you are required to submit a Hazardous

Waste Report indicating the amount of hazardous was te you generate, treat, ship off-site, or receive

from off-site, you must fill out this form.

• Site was a TSD facility and/or generator of ≥ 1,000 kilograms (kg) of hazardous waste, >1 kg of

acute hazardous waste, or >100 kg of acute hazardou s waste spill cleanup in one or more months of

the report year (Only a TSD facility and/or Large Q uantity Generator should place an “X” in this

box.)

Item 2 – Site EPA ID Number:

NOTE: If this is your initial notification for this site, leave this item blank and proceed to Item 3.

Write the EPA ID Number assigned to this site location address in Item 2. Be sure to include your

EPA ID Number on any additional sheets.Revised 6/14/2013 

### 3 Item 3 – Site Name:

Enter the legal name of the facility which is condu cting business at this site.

Item 4 – Site Location Information:

Enter the physical address or location for this sit e. The address or location must be a physical

address, not a post office box or route number. Th is is your 911 system location address.

NOTE : A new EPA ID Number is required if you move to a new location.

- If your new location does not have an EPA ID Numb er, a new EPA ID Number will be assigned.

- If your new location has a previously assigned EP A ID Number, you will use the existing number.

Item 5 – Site Land Type:

Place an "X" in the box that best describes the land type for your site. Select only one type: Private,

County, District, Federal, Tribal, Municipal, State , or Other. If Other is selected, explain this in Item

12 – Comments.

Item 6 – North American Industry Classification Sys tem (NAICS) Code(s):

Box A must be completed. Completing Boxes B-D is r ecommended, if applicable.

Box A

Enter the NAICS code that best describes your site’s primary business product ion process for

your products or services . Use the 6-digit code (most specific description) if available for your

business; if not, use the 5-digit code; do not enter any codes with less than 5 digits.

Boxes B - D

List other NAICS codes that describe the primary bu siness production processes for your site. Use

the most specific 6- or 5-digit code available; do not enter any codes with less than 5 digits.

You can obtain information about NAICS Codes from t he following sources:



## http://www.census.gov/eos/www/naics/ or http://www.naics.com/search.htm

Item 7 – Site Mailing Address:

Write the site’s mailing address. If the site’s ma iling address and the site’s location address are t he

same, you may write “SAME”.

Item 8 – Site Contact Person:

Enter the name, mailing address, email, business ph one number and extension, and fax number of the

person who should be contacted about information su bmitted on the form. A Subsequent Notification

is required when the Site Contact Person changes.

Item 9 – Legal Owner and Operator of the Site:

Enter the name or names of each legal owner and ope rator of this site. For the meaning of owner and

operator, see the definitions provided in these ins tructions. Use Item 12 – Comments and additional

sheets, if necessary.

A. Name of Site’s Legal Owner : Enter the name, mailing address and telephone of each of the

site’s legal owners. If this is either an Initial or Subsequent Notification, please enter any

additional owner(s) or any deleted owner(s) since t he last notification. Please provide dates

they became or ceased being an owner. Use Item 12 – Comments to enter information.

Date Became Owner: Enter the date on which the person or entity became the legal owner of

site.Revised 6/14/2013 

### 4

Owner Type: Place an "X" in the box that best describes the owner type of your site. Select

only one type: Private, County, District, Federal, Tribal, Municipal, State, or Other. If Other,

explain under Item 12 – Comments.

Owner Mailing Address: Write the mailing address and telephone number of owner.

B. Legal Operator: Write the name of your site’s operator. If it is the same as the owner, write

“SAME”.

Date Became Operator: Write the date on which the person or entity became the operator of

site.

Operator Type: Same as instructions for Owner Type.

NOTE : A Subsequent Notification is required when the ow ner or operator of a site changes. Because

an EPA ID Number is site-specific, the new owner wi ll use the existing EPA ID Number assigned to

the site.

Item 10 – Type of Regulated Waste Activity :

A. Hazardous Waste Activities: Place an "X" in the appropriate box to indicate eac h hazardous

waste activity being conducted at this site.

NOTE : Do NOT use the federal generator classifications fo und in 40 CFR. Use the State of

Kansas generator classifications described in the f ollowing paragraphs to complete this form

.

1. Generator of Hazardous Waste : If you generate a hazardous waste that is listed in 40 CFR

261.31 through 261.33 or is identified by one or mo re hazardous waste characteristic(s)

contained in 40 CFR 261.21 through 261.24, place an "X" in the box corresponding to the total

quantity of non-acute hazardous waste that is gener ated in any single calendar month. Do

NOT average over months; rather enter the highest sing le monthly total. The definitions for

the four classifications of hazardous waste generat ors in Kansas are found in K.A.R. 28-31-

260(c)(2)(E) and K.A.R. 28-31-260a(a)(1), (8), and (9). A brief description of the four classes

of hazardous waste generators in Kansas follows.

a. LQG: Large Quantity Generator

This site is classified as a LQG if the site meets any of the following criteria:

i Generates, in any single calendar month, 1,000 k g (2,200 lb) or more of hazardous waste;

or

ii Generates, in any single calendar month, or acc umulates at any time, more than 1 kg (2.2

lb) of acute hazardous waste; or

iii Generates, in any single calendar month, or ac cumulates at any time, more than 100 kg

(220 lb) of any residue or contaminated soil, waste , or other debris resulting from the

cleanup of a spill of any acute hazardous waste

NOTE : If, in addition to being a LQG Generator, you rec ycle hazardous wastes at your site (without

storing the wastes before you recycle them), mark b oth this box and Box A.7.Revised 6/14/2013 

### 5

b. SQG: Small Quantity Generator

This site is classified as a SQG if the site meets any of the following criteria:

i Generates, in any single calendar month, more tha n 100 kg (220 lb) but less than 1,000 kg

(2,200 lb) of hazardous waste; and

ii Accumulates, at any time, no more than 6,000 kg (13,200 lb) of hazardous waste; and

iii Generates, in any single calendar month, or ac cumulates at any time, no more than 1 kg

(2.2 lb) of acute hazardous waste; and

iv Generates, in any single calendar month, or acc umulates at any time, more than 100 kg

(220 lb) of any residue or contaminated soil, waste , or other debris resulting from the

cleanup of a spill of any acute hazardous waste.

c. KSQG: Kansas Small Quantity Generator

This site is classified as a KSQG if the site meets any of the following conditions:

i. Generates, in any single calendar month, 25 kg (55 lb) or more but less than 100 kg (220

pounds) of hazardous waste; and

ii. Accumulates, at any time, no more than 1,000 k g (2,200 lb) of hazardous waste; and

iii Generates, in any single calendar month, or ac cumulates at any time, no more than 1 kg

(2.2 lb) of acute hazardous waste; and

iv Generates, in any single calendar month, or accu mulates at any time, more than 100 kg

(220 lb) of any residue or contaminated soil, waste , or other debris resulting from the

cleanup of a spill of any acute hazardous waste.

d. CESQG: Conditionally Exempt Small Quantity Generato r

This site is classified as a CESQG if the site meet s all of the following conditions:

i Generates, in any single calendar month, less tha n 25 kg (55 lb) of hazardous waste; and

ii Accumulates, at any time, no more than 1,000 kg (2,200 lb) of hazardous waste; and

iii Generates, in any single calendar month, or ac cumulates at any time, no more than 1 kg

(2.2 lb) of acute hazardous waste, and

iv Generates, in any single calendar month, or accu mulates at any time, more than 100 kg

(220 lb) of any residue or contaminated soil, waste , or other debris resulting from the

cleanup of a spill of any acute hazardous waste.

NOTE : If you generate acute hazardous wastes listed in 40 CFR 261.31, 261.32 or 261.33(e), please

refer to K.A.R. 28-31-261 and 40 CFR 261.5(e) to de termine the circumstances under which you must

notify the KDHE.

In addition to indicating the generator class, plac e an “X” in each appropriate box to indicate other

generator activities occurring at this site . Please mark all boxes that apply.

2. Short-Term Generator (generate from a short-term or one-time event and n ot from on-going

processes). If “Yes”, provide an explanation in th e Comments section.

3. United States Importer of Hazardous Waste : Place an "X" in the box if you import

hazardous waste from a foreign country into the Uni ted States. Refer to 40 CFR 262.60 for

additional information.Revised 6/14/2013 

### 6

4. Mixed Waste Generator : Place an "X" in the box if you are a generator of mixed waste.

Mixed waste is waste that contains both hazardous w aste and radioactive waste. Radioactive

waste includes source, special nuclear, or by-produ ct material subject to the Atomic Energy

Act (AEA). Refer to RCRA section 1004(41), 42 U.S.C . 6903 (63 FR 17414; April 9, 1998).

5. Transporter of Hazardous Waste: If you transport hazardous waste within the Unite d States

and/or own or operate a hazardous waste transfer fa cility, place an “X” in each appropriate box

to indicate each hazardous waste management activit y. The Kansas regulations for hazardous

waste transporters are found in K.A.R. 28-31-6, K.A .R. 28-31-263, and K.A.R. 28-31-263a.

6. Treater, Storer, or Disposer of Hazardous Waste: If you treat, store, or dispose of regulated

hazardous waste that is subject to a permit or inte rim status, place an "X" in this box. A

hazardous waste permit is required for these activi ties. NOTE: Burning hazardous wastes in

boilers and industrial furnaces and storing hazardo us wastes before recycling fall into this

category. For permitted activities, please contact KDHE at 785-296-1600 to request a

Hazardous Waste Part A Permit Application in additi on to this notification.

NOTE : If your site is a destination facility for univer sal wastes in addition to being a treatment,

storage, or disposal facility for other hazardous w astes, mark both this box and Box B.2.

7. Recycler of Hazardous Waste: If you recycle regulated hazardous wastes (recyclab le

materials), place an “X” in this box. The regulati ons for owners or operators of sites that

recycle hazardous waste are found in 40 CFR 261.6. A hazardous waste permit may be

required for this activity.

NOTE : If your site, in addition to being a recycling si te for hazardous waste, treats, stores, or

disposes of hazardous waste, mark both this box and Box A.6. If your site is a destination

facility for universal wastes in addition to being a recycling site for other hazardous wastes,

mark both this box and Box B.2.

8. Exempt Boiler and/or Industrial Furnace:

a. If you burn small quantities of hazardous waste in an on-site boiler or industrial furnace in

accordance with the conditions in 40 CFR 266.108, p lace an “X” in the box to indicate that

you qualify for the Small Quantity On-Site Burner E xemption.

b. If you process hazardous wastes in a smelting, m elting, or refining furnace solely for

metals recovery, as described in 40 CFR 266.100(d), or to recover economically significant

amounts of precious metals, as described in 40 CFR 266.100(g), or if you process

hazardous wastes in a lead recovery furnace to reco ver lead, as described in 40 CFR

266.100(h), place an “X” in the box to indicate tha t you qualify for the Smelting, Melting,

and Refining Furnace Exemption.

9. Underground Injection Control: If you generate, treat, store, or dispose of hazard ous waste

and there is an underground injection well located at your site, place an "X" in the box. The

regulations for owners or operators of underground injection wells are found in 40 CFR Part

148.

10. Receives Hazardous Waste From Off-site (at your site): If you received hazardous waste

from another site, whether this waste was received as a commercial transaction or waste

received from a restricted group of off-site genera tors, place an “X”.Revised 6/14/2013 

### 7 B. Universal Waste Activities: Refer to K.A.R. 28-31-273, 40 CFR 261.9, and 40 CFR Part 273 for

the regulations covering universal waste.

1. Large Quantity Handler of Universal Waste (LQHUW ): You are an LQHUW if you

accumulate a total of 5,000 kg (11,000 pounds) or m ore of any universal wastes (calculated

collectively) at any time. Place an “X” in the app ropriate box to indicate the type of universal

wastes you generate and/or accumulate at your site.

2. Destination Facility: Place an "X" in the box if you treat, dispose of, or recycle universal

wastes on site. A hazardous waste permit is requir ed if you treat or dispose of universal

wastes. A permit may be required if you recycle uni versal wastes.

NOTE: If your site, in addition to being a destination fa cility for universal wastes, is also a treatment,

storage, or disposal facility for hazardous wastes, mark both this box and box A.6. In addition, if y our

site recycles hazardous wastes, mark both this box and box A.7.

C. Used Oil Activities: Place an “X” in each appropriate box to indicate e ach used oil management

activity taking place at this site. The Kansas regulations for used oil management are found in

K.A.R. 28-31-6, K.A.R. 28-31-279 and K.A.R. 28-31-2 79(a).

1. Used Oil Transporter: If you transport used oil and/or own or operate a u sed oil transfer

facility, place an "X" in each appropriate box to i ndicate each used oil management activity.

2. Used Oil Processor/Re-Refiner: If you process and/or re-refine used oil, place an "X" in each

appropriate box to indicate each used oil managemen t activity.

3. Off-Specification Used Oil Burner: If you burn off-specification used oil fuel, place an "X"

in this box to indicate this used oil management ac tivity.

4. Used Oil Fuel Marketer: If you market off-specification used oil directly to a burner, place

an "X" in Box 4.a. If you are the first to claim t he used oil meets the used oil specification

listed in 40 CFR 279.11, place an "X" in Box 4.b. If either of these boxes is marked, you also

must notify (or must have previously notified) as aused oil transporter, used oil processor/rerefiner, or off-specification used oil fuel burner. If you are only a used oil generator, you are

not required to notify unless you conduct any of th e previously described used oil activities.

Item 11 – Description of Hazardous Wastes:

You will need to refer to K.A.R. 28-31-261, K.A.R. 28-31-261a, and 40 CFR 261 to complete this

item. Part 261 identifies those solid wastes which are defined as hazardous and regulated under the

hazardous waste regulations. You may obtain inform ation regarding the types of regulated hazardous

waste by contacting the Bureau of Waste Management at 785-296-1600. This information is also

available on BWM’s website: www.kdheks.gov/waste Please click on the link Hazardous Waste

Generators Program and then scroll down and click o n Hazardous Waste Generator Handbook. The

handbook may be printed.

Regulated Hazardous Waste Codes: If you manage hazardous wastes that are described in 40 CFR

Part 261, write each appropriate 4-digit code in th e boxes provided.

NOTE : If you need to list more than will fit under Item 11, please continue listing the

hazardous waste codes either under Item 12 – Commen ts or on an extra sheet. If you use an extra

sheet, include your EPA ID number on the top of the sheet and attach it to the form.Revised 6/14/2013 

### 8 Item 12 – Comments:

Use this section as needed to provide additional in formation for Items 1 through 11. You may attach

additional sheets if necessary. Please enter your EPA ID Number on any additional s heets.

Item 13 – Certification:

This certification must be signed by owner(s), oper ator(s), or authorized representative(s) for the si te.

NOTE: All notification forms must include this sign ed and dated certification to be considered

complete.



## Return the Completed Notification Form To:

Sarah Fulton

KDHE-BWM

1000 SW Jackson, Suite 320

Topeka, KS 66612-1366

ADDITIONAL INFORMATION

Transporters:

Hazardous Waste and Used Oil Transporters must also complete a Transporter Registration form. The

forms can be found on the BWM website or by using t he following link:



## http://www.kdheks.gov/waste/forms_hazwaste.html#hwg en

Fee Payment:

KAR 28-31-10 sets the monitoring fees for hazardous waste activities. A listing of the fees can be

found on the BWM website or by using the following link:



## http://www.kdheks.gov/waste/p_hwfees.html

Transporters will submit the fee with the Transport er Registration form. Generators will receive an

invoice for the fee.Revised 6/14/2013 

### 9 

# DEFINITIONS

The following definitions are included to help you to understand and complete the form:

Act or RCRA means the Solid Waste Disposal Act, as amended by t he Resource Conservation and

Recovery Act of 1976, as amended by the Hazardous a nd Solid Waste Amendments of 1984,

42 U.S.C. Section 6901 et seq.

Acutely Hazardous Waste means wastes that are highly toxic commercial chemi cal products, offspecification chemicals, or container residues and residues from the spillage of these chemicals

that are discarded or intended to be discarded. Th ese highly toxic chemicals have been

identified by EPA as always being acutely hazardous wastes when disposed. EPA has

developed a list of these chemicals, called the P-l ist, which is contained in 40 CFR 261.33(e).

These P-listed chemicals include commercially pure grades of the chemicals, any technical

grades of these chemicals that are produced or mark eted, and all formulations in which only

one of the P-listed chemicals is the sole active in gredient. An example of an acutely hazardous

waste would be a P-listed pesticide such as parathi on (P089) that must be disposed. Examples

of generators that generate acutely hazardous waste s are pesticide applicators, laboratories, and

chemical formulators.

Authorized Representative means the person responsible for the overall operat ion of the RCRA site

or an operational unit (i.e., part of an RCRA site) , e.g., superintendent or plant manager, or

person of equivalent responsibility.

Boiler means an enclosed device using controlled flame com bustion and having the following

characteristics:

1. The unit has physical provisions for recovering and exporting energy in the form of steam,

heated fluids, or heated gases;

2. The unit's combustion chamber and primary energy recovery section(s) are of integral

design (i.e., they are physically formed into one m anufactured or assembled unit);

3. The unit continuously maintains an energy recove ry efficiency of at least 60 percent,

calculated in terms of the recovered energy compare d with the thermal value of the fuel;

4. The unit exports and utilizes at least 75 percen t of the recovered energy, calculated on an

annual basis (excluding recovered heat used interna lly in the same unit, for example, to

preheat fuel or combustion air or drive fans or fee d water pumps); or

5. The unit is one which the KDHE has determined, o n a case-by-case basis, to be a boiler,

after considering the standards in 40 CFR 260.32.

Disposal means the discharge, deposit, injection, dumping, s pilling, leaking, or placing of any solid

waste or hazardous waste into or on any land or wat er so that such solid waste or hazardous

waste or any constituent thereof may enter the envi ronment or be emitted into the air or

discharged into any waters, including ground waters

.

EPA Identification (ID) Number means the number assigned by KDHE to each hazardous waste

generator, hazardous waste transporter, and treatme nt, storage, or disposal RCRA site; large

quantity handler of universal wastes; used oil tran sporter, used oil processor/re-refiner, offspecification used oil fuel burner, and used oil fu el marketer.Revised 6/14/2013 

### 10 Hazardous Waste means a hazardous waste as defined in 40 CFR 261.3.

Hazardous Waste Generator means any person, by site, whose act or process pro duces hazardous

waste identified or listed in 40 CFR Part 261 or whose act first causes a hazardous wast e to

become subject to regulation.

Hazardous Waste Storage means the holding of hazardous waste for a temporar y period, at the end

of which the hazardous waste is treated, disposed o f, or stored elsewhere.

Hazardous Waste Transporter means a person engaged in the off-site transportati on of hazardous

waste by air, rail, highway, or water.

Hazardous Waste Transfer Facility means a site that holds manifested hazardous wastes at their site

for a period of ten (10) days or less while the was te is in transit. The Federal regulations for

hazardous waste transfer facilities are found in 40 CFR Part 263.12.

Hazardous Waste Treatment means any method, technique, or process, including neutralization,

designed to change the physical, chemical, or biolo gical character or composition of any

hazardous waste so as to neutralize such hazardous waste, or so as to recover energy or

material resources from the hazardous waste, or so as to render such hazardous waste

nonhazardous, or less hazardous; safer to transport , store or dispose of; or amenable for

recovery, amenable for storage, or reduced in volum e. Such term includes any activity or

processing designed to change the physical form or composition of hazardous waste so as to

render it nonhazardous.

Industrial Furnace means any of the following enclosed devices that ar e integral components of

manufacturing processes and that use thermal treatm ent to accomplish recovery of materials or

energy: cement kilns; lime kilns; aggregate kilns; phosphate kilns; coke ovens; blast furnaces;

smelting, melting and refining furnaces; titanium d ioxide chloride process oxidation reactors;

methane reforming furnaces; pulping liquor recovery furnaces; combustion devices used in the

recovery of sulfur values from spent sulfuric acid; halogen acid furnaces, as defined under

industrial furnace in 40 CFR 260.10; and such other devices as the KDHE may add to this list.

Large Quantity Handler of Universal Waste means a universal waste handler (as defined in 40 C FR

273.6) who accumulates 5,000 kilograms (11,000 poun ds) or more total of universal waste

(batteries, pesticides, or thermostats, collectivel y) at any time. This designation is retained

through the end of the calendar year in which 5,000 kilograms or more of universal wastes are

accumulated.

Municipality means a city, village, town, borough, county, paris h, district, association, Indian tribe or

authorized Indian tribal organization, designated a nd approved management agency under

Section 208 of the Clean Water Act, or any other pu blic body created by or under State law and

having jurisdiction over disposal of sewage, indust rial wastes, or other wastes.

Off-Specification Used Oil Burner means an site where used oil not meeting the speci fication

requirements in 40 CFR 279.11 (off-specification us ed oil) is burned for energy recovery in

devices identified in Section 279.61(a).

Off-Specification Used Oil Fuel means used oil fuel that does not meet the specific ation provided

under 40 CFR 279.11.Revised 6/14/2013 

### 11 On-Specification Used Oil Fuel means used oil fuel that meets the specification pr ovided under 40

CFR 279.11.

Operator means the person responsible for the overall operat ion of a site. See Person

.

Owner means a person who owns a site or part of a site, i ncluding the property owner. See Person

.

Person means an individual, trust, firm, joint stock comp any, Federal Agency, corporation (including

a government corporation), partnership, association , State, municipality, commission, political

subdivision of a State, or any interstate body.

RCRA Subtitle C Site (Site) means the physical plant or location at which one or more of the

following regulated waste activities occurs: the ge neration, transportation, treatment, storage,

or disposal of hazardous wastes; recycling of hazar dous wastes; the accumulation of 5,000 kg

(11,000 pounds) or more of universal wastes; and th e transportation (and temporary storage

during transportation), processing/re-refining, bur ning, or marketing of used oil. A site may

consist of several treatment, storage, or disposal operational units. A site also may consist of

an area undergoing corrective action. (For entitie s that only transport regulated wastes, the

term site refers to the headquarters of that entity = s operations.)

Small Quantity On-Site Burner Exemption means that persons who burn small quantities of

hazardous waste in an on-site boiler or industrial furnace, in accordance with 40 CFR 266.108,

are conditionally exempt from regulation for that a ctivity.

Smelting, Melting, and Refining Furnace Exemption means that: owners or operators of smelting,

melting, and refining furnaces that process hazardo us waste solely for metal recovery are

conditionally exempt from regulation, except for 40 CFR 266.101 and 266.112, provided they

comply with the requirements in Section 266.100(d); owners or operators of smelting, melting

and refining furnaces that process hazardous waste for recovery of precious metals are

conditionally exempt from regulation, except for 40 CFR 266.112, provided they comply with

the requirements in Section 266.100(g); and owners or operators of lead recovery furnaces that

process hazardous waste for recovery of lead and th at are subject to regulation under the

Secondary Lead Smelting NESHAP are conditionally ex empt from regulation, except for 40

CFR 266.101, provided they comply with the requirem ents in Section 266.100(h).

Underground Injection Control means the subsurface emplacement of fluids through a bored, drilled

or driven well; or through a dug well, where the de pth of the dug well is greater than the largest

surface dimension. Underground injection wells are regulated under both the Safe Drinking

Water Act and the Resource Conservation and Recover y Act (see 40 CFR Part 148).

Used Oil means any oil that has been refined from crude oil , or any synthetic oil, that has been used,

and as a result of such use, is contaminated by phy sical or chemical impurities.

Used Oil Fuel Marketer means any person who conducts either of the follow ing activities:

1. Directs a shipment of off-specification used oil from their site to an off-specification used

oil burner; or

2. First claims that used oil that is to be burned for energy recovery meets the used oil fuel

specifications set forth in 40 CFR 279.11.Revised 6/14/2013 

### 12 Used Oil Activities , for the purposes of EPA Form 8700-12, include use d oil transporter and transfer

facility; used oil processing and re-refining; off- specification used oil burner; and used oil fuel

marketing.

Used Oil Processing means chemical or physical operations designed to produce from used oil, or to

make used oil more amenable for production of, fuel oils, lubricants, or other used oil-derived

products. Processing includes, but is not limited to: blending used oil with virgin petroleum

products, blending used oils to meet the fuel speci fication, filtration, simple distillation,

chemical or physical separation, and re-refining.

Used Oil Processor means an site that processes on- or off-specificat ion used oil.

Used Oil Re-Refiner means an site that produces lubricating oils and g reases, industrial fuel, asphalt

extender, gasoline, and other products from on- or off-specification used oil.

Used Oil Transfer Facility means any transportation-related facility, includi ng loading docks,

parking areas, storage areas, and other areas where shipments of used oil are held for more than

24 hours during the normal course of transportation and not longer than 35 days. Transfer

facilities that store used oil for more than 35 day s are subject to regulation under 40 CFR Part

279, Subpart F.

Used Oil Transporter means any person who transports used oil, any pers on who collects used oil

from more than one generator and transports the col lected oil, and owners and operators of

used oil transfer facilities. Used oil transporter s may consolidate or aggregate loads of used oil

for purposes of transportation but, with the follow ing exception, may not process used oil.

Used oil transporters may conduct incidental proces sing operations that occur in the normal

course of used oil transportation (e.g., settling a nd water separation), but that are not designed

to produce (or make more amenable for production of ) used oil-derived products or used oil

fuel.Page 1 of 6 EPA ID Number

Kansas Department of Health and Environment



## HARDOUS WASTE PERMIT INFORMATION FORM

1. Facility Permit

Contact First Name: MI: Last Name:

Contact Title:

Phone: Ext.: Email:

2. Facility Permit

Contact Mailing

Address Street or P.O. Box:

City, Town, or Village:

State:

Country: Zip Code:

3. Operator Mailing

Address and

Telephone Number Street or P.O. Box:

City, Town, or Village:

State: Phone:

Country: Zip Code:

4. Facility Existence

Date Facility Existence Date (mm/dd/yyyy):

5. Other Environmental Permits

A. Facility Type

(Enter code) B. Permit Number C. Description

6

. Nat u r e of B u si n ess:EPA ID Number

7. Process Codes and Design Capacities – Enter inf ormation in the Section on Form Page 3

A. PROCESS CODE – Enter the code from the list of process codes bel ow that best describes each process to be used at t he facility. If more lines

are needed, attach a separate sheet of paper with t he additional information. For “other” processes (i .e., D99, S99, T04 and X99), describe the

process (including its design capacity) in the spac e provided in Item 8.

B. PROCESS DESIGN CAPACITY – For each code entered in Item 7.A; enter the capa city of the process.

1. AMOUNT – Enter the amount. In a case where design capacity is not applicable (such as in a closure/post-closu re or enforcement action)

enter the total amount of waste for that process.

2. UNIT OF MEASURE – For each amount entered in Item 7.B(1), enter the code in Item 7.B(2) from the list of unit of measu re codes below that

describes the unit of measure used. Select only fro m the units of measure in this list.

C. PROCESS TOTAL NUMBER OF UNITS – Enter the total number of units for each correspo nding process code.

Process Appropriate Unit of Measure for Process Process Appropriate Unit of Measure for

Code Process Design Capacity

Disposal Treatment (Continued) (for T81 – T94)

D79 Underground Injection Gallons; Liters; Gallons Per Day; or

Well Disposal Liters Per Day

D80 Landfill Acre-feet; Hectares-meter; Acres;

Cubic Meters; Hectares; Cubic

Yards

D81 Land Treatment Acres or Hectares

D82 Ocean Disposal Gallons Per Day or Liters Per Da y

D83 Surface Impoundment Gallons; Liters; Cubic Mete rs; or

Disposal Cubic Yards

D99 Other Disposal Any Unit of Measure Listed Below T81 Cement Kiln Gallons Per Day; Liters Per Day; Po unds

Per Hour; Short Tons Per Hour;

Kilograms Per Hour; Metric Tons Per

T82 Lime Kiln Day; Metric Tons Per Hour; Short Tons

Per Day; BTU Per Hour; Liters Per Hour;

T83 Aggregate Kiln Kilograms Per Hour; or Million BTU Per

T84 Phosphate Kiln

T85 Coke Oven

T86 Blast Furnace

T87 Smelting, Melting, or Refining Furnace

T88 Titanium Dioxide Chloride Oxidation Reactor

T89 Methane Reforming Furnace

T90 Pulping Liquor Recovery Furnace

T91 Combustion Device Used in the Recovery of Sulfu r Values from Spent

Sulfuric Acid

T92 Halogen Acid Furnaces

T93 Other Industrial Furnaces Listed in 40 CFR 260. 10

T94 Containment Building Cubic Yards; Cubic Meters; Short Tons

Treatment Per Hour; Gallons Per Hour; Liters Per

Hour; BTU Per Hour; Pounds Per Hour;

Short Tons Per Day; Kilograms Per

Hour; Metric Tons Per Day; Gallons Per

Day; Liters Per Day; Metric Tons Per

Hour; or Million BTU Per Hour Storage

S01 Container Gallons; Liters; Cubic Meters; or

Cubic Yards

S02 Tank Storage Gallons; Liters; Cubic Meters; or

Cubic Yards

S03 Waste Pile Cubic Yards or Cubic Meters

S04 Surface Impoundment Gallons; Liters; Cubic Meters; or

Cubic Yards

S05 Drip Pad Gallons; Liters; Cubic Meters;

Hectares; or Cubic Yards

S06 Containment Building Cubic Yards or Cubic Meter s

Storage

S99 Other Storage Any Unit of Measure Listed Below

Trea t me nt

T01 Tank Treatment Gallons Per Day; Liters Per Day

T02 Surface Impoundment Gallons Per Day; Liters Per Day

T03 Incinerator Short Tons Per Hour; Metric Tons

Per Hour; Gallons Per Hour; Liters

Per Hour; BTUs Per Hour; Pounds

Per Hour; Short Tons Per Day;

Kilograms Per Hour; Gallons Per

Day; Metric Tons Per Hour; or

Million BTU Per Hour

T04 Other Treatment Gallons Per Day; Liters Per Day ;

Pounds Per Hour; Short Tons Per

Hour; Kilograms Per Hour; Metric

Tons Per Day; Short Tons Per Day;

BTUs Per Hour; Gallons Per Day;

Liters Per Hour; or Million BTU Per

Hour

T80 Boiler Gallons; Liters; Gallons Per Hour;

Liters Per Hour; BTUs Per Hour; or

Million BTU Per Hour Miscellan e ou s (S ubpa r t X)

X01 Open Burning/Open Any Unit of Measure Listed Be low

Detonation

X02 Mechanical Processing Short Tons Per Hour; Metr ic Tons Per

Hour; Short Tons Per Day; Metric Tons

Per Day; Pounds Per Hour; Kilograms

Per Hour; Gallons Per Hour; Liters Per

Hour; or Gallons Per Day

X03 Thermal Unit Gallons Per Day; Liters Per Day; P ounds

Per Hour; Short Tons Per Hour;

Kilograms Per Hour; Metric Tons Per

Day; Metric Tons Per Hour; Short Tons

Per Day; BTU Per Hour; or Million BTU

Per Hour

X04 Geologic Repository Cubic Yards; Cubic Meters; Acre-feet;

Hectare-meter; Gallons; or Liters

X99 Other Subpart X Any Unit of Measure Listed Belo w

Unit of Measure Unit of Measure Code Unit of Measure Unit of Measure Code Unit of Measure Unit of Measure Code

Gallons

................................ ................. G Short Tons Per Hour

............................... . D Cubic Ya r d s

.............................................. Y

Gallons Per H ou r

................................. . E Short Tons Per D a y

................................. . N Cubic M eters

............................................ C

Gallons Per D a y ...................................U Metric Tons Per Hour

.............................. W A cres

................................................... ...... B

Liters

.......................... ........................... L Metric Tons Per D a y

................................. S A c r e

- f e et

................................................... A

Liters Per H our .....................................H Pounds Per H our

................................... ... J Hectare s

................................................... . Q

Liters Per D a y

...................................... . V Kilogr a m s Per Hour

................................. X Hectar e

- m e te r ............................................F

Million B T U P er Hour

............................... X BTU Per H our

............................................ . I

Page 2 of 6Page 3 of 6 EPA ID Number

7. Process Codes and Design Capacities (Continued)

EXAMPLE FOR COMPLETING Item 7 (shown in line number X-1 below): A facility has a storage tank, which c an hold 533.788 gallons.

Line

Number A. Process

Code

(From list above) B. PROCESS DESIGN CAPACITY C. Process Total For Official Use Only

(1) Amount (Specify) (2) Unit of Measure Number of Units

X 1 S 0 2 533.788 G 001

1

2

3

4

5

6

7

8

9

1 0

1 1

1 2

1 3

Note: If you need to list more than 13 process code s, attach an additional sheet(s) with the informati on in the same format as above.

Number the line sequentially, taking into account a ny lines that will be used for “other” process (i.e ., D99, S99, T04, and X99) in Item 8.

8. Other Processes (Follow instructions from Item 7 for D99, S99, T04, and X99 process codes)

Line

Number

(Enter #s in

sequence

with Item 7) A. Process Code

(From list above) B. PROCESS DESIGN CAPACITY

(1) Amount (Specify) (2) Unit of

Measure C. Process Total For Official Use Only

Number of Units

X 2 T 0 4 100.00 U 001Page 4 of 6 ENGLISH UNIT OF MEASURE CODE METRIC UNIT OF

MEASURE CODE

POUNDS

TONS P

T KILOGRAMS

METRIC TONS K

M EPA ID Number

9. Description of Hazardous Wastes - Enter Informa tion in the Sections on Form Page 5

A. EPA HAZARDOUS WASTE NUMBER – Enter the four-digi t number from 40 CFR, Part 261 Subpart D of each li sted hazardous waste you will

handle. For hazardous wastes which are not listed i n 40 CFR, Part 261 Subpart D, enter the four-digit number(s) from 40 CFR Part 261, Subpart

C that describes the characteristics and/or the tox ic contaminants of those hazardous wastes.

B. ESTIMATED ANNUAL QUANTITY – For each listed wast e entered in Item 9.A, estimate the quantity of tha t waste that will be

handled on an annual basis. For each characteristic or toxic contaminant entered in Item 9.A, estimate the total annual

quantity of all the non-listed waste(s) that will b e handled which possess that characteristic or cont aminant.

C. UNIT OF MEASURE – For each quantity entered in I tem 9.B, enter the unit of measure code. Units of measure which must be

used and the appropriate codes are:

If facility records use any other unit of measure f or quantity, the units of measure must be converted into one of the required

units of measure, taking into account the appropria te density or specific gravity of the waste.

D. PROCESSES

1. PROCESS CODES:

For listed hazardous waste: For each listed hazardo us waste entered in Item 9.A, select the code(s) fr om the list of

process codes contained in Items 7.A and 8.A on pag e 3 to indicate all the processes that will be used to store, treat,

and/or dispose of all listed hazardous wastes.

For non-listed waste: For each characteristic or to xic contaminant entered in Item 9.A, select the cod e(s) from the list of

process codes contained in Items 7.A and 8.A on pag e 3 to indicate all the processes that will be used to store, treat,

and/or dispose of all the non-listed hazardous wast es that possess that characteristic or toxic contam inant.

NOTE: THREE SPACES ARE PROVIDED FOR ENTERING PROCES S CODES. IF MORE ARE NEEDED:

1. Enter the first two as described above.

2. Enter “000” in the extreme right box of Item 9.D (1).

3. Use additional sheet, enter line number from pre vious sheet, and enter additional code(s) in Item 9 .E.

2. PROCESS DESCRIPTION: If code is not listed for a process that will be used, describe the process in Item 9.D(2) or in

Item 9.E(2).

NOTE: HAZARDOUS WASTES DESCRIBED BY MORE THAN ONE EPA HAZARDOUS WASTE NUMBER – Hazardous

wastes that can be described by more than one EPA H azardous Waste Number shall be described on the for m as follows:

1. Select one of the EPA Hazardous Waste Numbers an d enter it in Item 9.A. On the same line complete Items 9.B, 9.C,

and 9.D by estimating the total annual quantity of the waste and describing all the processes to be us ed to store,

treat, and/or dispose of the waste.

2. In Item 9.A of the next line enter the other EPA Hazardous Waste Number that can be used to describ e the waste. In

Item 9.D.2 on that line enter “included with above” and make no other entries on that line.

3. Repeat step 2 for each EPA Hazardous Waste Numbe r that can be used to describe the hazardous waste.

EXAMPLE FOR COMPLETING Item 9 (shown in line number s X-1, X-2, X-3, and X-4 below) – A facility will t reat and dispose of an

estimated 900 pounds per year of chrome shavings fr om leather tanning and finishing operations. In ad dition, the facility will treat

and dispose of three non-listed wastes. Two wastes are corrosive only and there will be an estimated 2 00 pounds per year of each

waste. The other waste is corrosive and ignitable and there will be an estimated 100 pounds per year of that waste. Treatment will

be in an incinerator and disposal will be in a land fill.

Line

Number A. EPA Hazardous

Waste No.

(Enter code) B. Estimated

Annual

Qty of

Waste C. Unit of

Measure

(Enter code) D. PROCESSES

(1) PROCESS CODES (Enter Code) (2) PROCESS DESCRIPTION

(If code is not entered in 9.D(1))

X 1 K 0 5 4 900 P T 0 3 D 8 0

X 2 D 0 0 2 400 P T 0 3 D 8 0

X 3 D 0 0 1 100 P T 0 3 D 8 0

X 4 D 0 0 2 Included With AboveEPA ID Number

9. Description of Hazardous Wastes (Continued. Use additional sheet(s) as necessary; number pages as 5a, etc.)

Line Number A. EPA Hazardous

Waste No.

(Enter code) B. Estimated

Annual

Qty of

Waste C. Unit of

Measure

(Enter code) D. PROCESSES

(1) PROCESS CODES (Enter Code) (2) PROCESS DESCRIPTION

(If code is not entered in 9.D(1))

1

2

3

4

5

6

7

8

9

1 0

1 1

1 2

1 3

1 4

1 5

1 6

1 7

1 8

1 9

2 0

2 1

2 2

2 3

2 4

2 5

2 6

2 7

2 8

2 9

3 0

3 1

3 2

3 3

3 4

3 5

3 6

Page 5 of 6EPA ID Number

9. Description of Hazardous Wastes (Continued. Use additional sheet(s) as necessary; number pages as 5a, etc.)

Line Number A. EPA Hazardous

Waste No.

(Enter code) B. Estimated

Annual

Qty of

Waste C. Unit of

Measure

(Enter code) D. PROCESSES

(1) PROCESS CODES (Enter Code) (2) PROCESS DESCRIPTION

(If code is not entered in 9.D.1)

Page 5 ofEPA ID Number

10. Map

Attach to this application a topographical map, or other equivalent map, of the area extending to at l east one mile beyond property

boundaries. The map must show the outline of the f acility, the location of each of its existing intak e and discharge structures, each of its

hazardous waste treatment, storage, or disposal fac ilities, and each well where it injects fluids unde rground. Include all spring, rivers, and

other surface water bodies in this map area. See i nstructions for precise requirements.

11. Facility Drawing

All existing facilities must include a scale drawin g of the facility (see instructions for more detail ).

12. Photographs

All existing facilities must include photographs (a erial or ground-level) that clearly delineate all e xisting structures; existing storage,

treatment, and disposal areas; and sites of future storage, treatment, or disposal areas (see instruct ions for more detail).

13. Comments

Page 6 of 6

## Instructions for Filling Out the

Hazardous Waste Permit Information Form

General

Instructions

Please type or print, leaving only one blank box be tween words. Abbreviate, if necessary, to stay with in

the number of boxes allowed for each item. Some ite ms in the form require narrative explanation. If

more space is necessary to answer a question, use t he space provided in Item 13 and reference the item

number to which the additional information applies or attach a separate sheet entitled “Additional

Information”. Remember to include your EPA Identifi cation Number and site name in the upper lefthand corner of each attached page.

Unless otherwise specified in the instructions to t he form, each item must be answered. To indicate th at

each item has been considered, enter “NA” for not a pplicable, if a particular item does not fit the

circumstances or characteristics of your facility o r activity.

For a Revised Part A Permit Application, circle the item numbers with new information or changes.

In addition to this form, the facility must also su bmit a Notification of Regulated Waste

Activity/Subtitle C Site Identification Form.

### Ha z ardous Waste Permit I n formation Form

(continued)

Instructions page 2 

### Item-By-Item Instructions

Item 1 – Facility Permit Contact

Give the name, title, work telephone number, and e- mail of a person who is thoroughly familiar with th e

activities at the facility that require a hazardous waste permit and with the facts reported in the Ha zardous

Waste Permit Information Form. This person must be available to be contacted by offices reviewing the

permit application, if necessary. If the Facility P ermit Contact person is the same as the Site Contac t

Person identified in Item 8 of the RCRA Subtitle C Site Identification Form (Site ID Form), you may

print “Same as Site Contact” in this box.

Item 2 – Facility Permit Contact Mailing Address

Enter the mailing address for the facility permit c ontact. If the mailing address is the same as the Site

Mailing Address (Item 7) on the Site ID Form, you m ay print “Same as Site Mailing Address” in this box

.

Item 3 – Operator Mailing Address and Telephone Num ber

Enter the mailing address and telephone number of t he facility operator identified in Item 9.B of the Site

ID Form.

Item 4 – Facility Existence Date

Enter the appropriate date that applies to your fac ility from among the following:

• the date that hazardous waste operations at the fac ility commenced;

• the date construction on the facility commenced; or

• the date operation is expected to begin.

Item 5 – Other Environmental Permits

A. Permit Type: Using the codes listed below, enter a letter on the form for all other environmental

permits the facility has received, or for which the facility has filed an application, even if the

permit has not yet been received.

N = NPDES (National Pollutant Discharge Elimination S ystem) Clean Water Act

P

= PSD (Prevention of S i gnif i cant Deterioration) Clean Air Act

R

= RCRA ( R es o u rce Conservation and Recovery Act)

U

= UIC (Underground I njection Cont r ol) Sa fe Drinking Water Act

F

= EPA 404 (D r e dge or Fill Pe r m its und e r Section 404 of the Clean Water Act)

E

= Other relevant environ m ental per m its. List any o ther relevant Federal (e .g.,

pe r m its under the Ocean D u m ping Act), State (e.g., State pe r m i ts for new air

e m ission sources in nona t tainment areas under Part D of the Clean Air Act or

State per m

its under Section 404 of t he Clean Water Act), or local environ m ental

per m its o r applications.

B. Permit Number: Give the number of each presently effective permit issued to the facility for

each program, or if you have previously filed an ap plication, but have not yet received a permit,

give the number of the application and note this in the description. You may list additional

permit numbers on a separate sheet of paper if you have more than one currently effective permit

### Ha z ardous Waste Permit I n formation Form

(continued)

Instructions page 3 for your facility under a particular permit program. Remember to include your EPA

Identification Number and site name in the upper le ft-hand corner of each attached page.

C. Description: Use the space provided for any additional informati on identifying or describing the

permits.

Item 6 – Nature of Business

Briefly describe the nature of your business (e.g., products produced or services provided). If more s pace

is needed, please attach additional sheets. Remembe r to include your EPA Identification Number and sit e

name in the upper left-hand corner of each attached page.

Item 7 – Process Codes and Design Capacities

The information in Item 7 describes all the process es that will be used to treat, store, or dispose of

hazardous waste at the facility. The process code a nd design capacity of each process must be provided

as part of the description. The design capacity of injection wells and landfills at existing facilitie s should

be measured as the remaining, unused capacity. Tank storage should refer to each tank, not each tank

farm. Please indicate the location of each process listed in Item 7 on either the map provided for Ite m 10

or the photographs provided for Item 12. Use the li ne number from Item 7 to indicate where the

process(es) are located. See the form for detailed instructions on Item 7.

NOTE Submission of a Revised Part A Permit Application i s required before processes for

treating, storing, or disposing of hazardous wastes are changed; before new processes are

added; and/or before the design capacities of these processes are increased.

Item 8 – Other Processes

Use this space to describe other processes that did not have a specific process code listed in Item 7. A of

the form. Follow the instructions for Item 7.A on t he form for other process codes (i.e., D99, S99, T0 4,

and X99 process codes). Describe the other processe s in Item 13 - Comments.

Item 9 – Description of Hazardous Wastes

This information describes all the hazardous wastes , using their hazardous waste codes, that will be

treated, stored, or disposed at the facility. In ad dition, the processes that will be used to treat, s tore, or

dispose of each hazardous waste and the estimated a nnual quantity of each hazardous waste must be

provided. The form contains three pages to capture the information for Item 9: Page 4 of 6, which has

detailed instructions; Page 5 of 6, which is to be filled out; and Page 5_ of _, which is used if addi tional

pages are needed. If additional pages are needed, t he pages should be numbered as follows: Page 5a of 6,

Page 5b of 6, Page 5c of 6, etc. See the form for d etailed instructions on Item 9.

### Ha z ardous Waste Permit I n formation Form

(continued)

Instructions page 4 NOTE Submission of a Revised Part A Permit Application i s required before a facility

begins treating, storing, or disposing of new hazardous wa stes not previously

identified in the facility’s Part A Permit Application. Changes in th e quantity of

hazardous waste previously specified in the Part A Permit Applicati on can be made

without submitting a Revised Part A Permit Application, provided the qua ntity does

not exceed the process design capacities specified in the first Part A sub mission.

Item 10 – Map

Provide a topographic map or maps of the area exten ding to at least one mile beyond the property

boundaries of the facility. The map must clearly sh ow the following:

• The legal boundaries of the facility;

• The location and serial number of each of your exis ting and proposed intake and discharge

structures;

• All hazardous waste management facilities;

• Location of all processes listed in Items 7 and 8 i dentified by process code;

• Each well where you inject fluids underground; and

• All springs and surface water bodies in the area, p lus all drinking water wells within 1⁄4 mile of the

facility which are identified in the public record or otherwise known to you.

If an intake or discharge structure, hazardous wast e disposal site, or injection well associated with the

facility is located more than one mile from the pla nt, include it on the map, if possible. If not, att ach

additional sheets describing the location of the st ructure, disposal site, or well, and identify the U .S.

Geological Survey (or other) maps corresponding to the location. Remember to include your EPA

Identification Number and site name in the upper le ft-hand corner of each attached page.

On each map, include the map scale, a meridian arro w showing north, and latitude and longitude at the

nearest whole second. On all maps of rivers, show t he direction of the current, and in tidal waters, s how

the directions of the ebb and flow tides. Use a 7-1 /2 minute series map published by the U.S. Geologic al

Survey. If a 7-1/2 minute series map has not been p ublished for your facility site, then you may use a 15-

minute series map from the U.S. Geological Survey. If neither a 7-1/2 nor 15-minute series map has bee n

published for your facility site, use a plant map o r other appropriate map, and include all the reques ted

information; in this case, briefly describe land us es in the map area (e.g., residential, commercial).

For information about obtaining maps, contact the U .S. Geological Survey at (888) 275-8747 or see the

USGS web site at http://www.usgs.gov/pubprod

.

You may trace your map from a geological survey cha rt, or other map meeting the above specifications.

If you do, your map should bear a note showing the number or title of the map or chart from which it w as

traced. Include the names of nearby towns, water bo dies, and other prominent points.

### Ha z ardous Waste Permit I n formation Form

(continued)

Instructions page 5 Item 11 – Facility Drawing

All existing facilities must include a drawing show ing the general layout of the facility. This drawin g

should be approximately to scale and fit on an 8 1⁄2” x 11” sheet of paper. The drawing should show the

following:

• The property boundaries of the facility;

• The areas occupied by all storage, treatment, or di sposal operations that will be used during

interim status;

• The name of each operation (e.g., multiple hearth i ncinerator, drum storage area, etc.);

• Areas of past storage, treatment, or disposal opera tions;

• Areas of future storage, treatment, or disposal ope rations; and

• The approximate dimensions of the property boundari es and all storage, treatment, and disposal

areas. (Where applicable, use the process codes lis ted in Items 7 and 8 to indicate the location of

all storage, treatment, and disposal areas.)

NOTE New facilities do not have to complete Item 11.

Item 12 – Photographs

All existing facilities must include photographs th at clearly delineate all existing structures; all e xisting

areas for storing, treating, or disposing of hazard ous waste; and all known sites of future storage,

treatment, or disposal operations. Photographs may be color or black and white, ground-level or aerial

. Indicate the date the photograph was taken on the b ack of each photograph. Use the process codes list ed

in Items 7 and 8 to indicate the location of all st orage, treatment, and disposal areas.

NOTE New facilities do not have to complete Item 12.

Item 13 – Comments

Use this space for any additional comments and atta ch additional sheets if necessary. Remember to

include your EPA Identification Number and site nam e in the upper left-hand corner of each attached

page.