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o r t h i s co l l e ct i o n o f i n f o r m at i o n i s es t i m at e d to av er age 0. 57 h o ur s per r e spo n se. T h i s est i m at e i n c ludes t i me f o r re a di ng ins truc t i o ns , s ear c h i ng e x i s t i n g data s o u r ces , gat h er i ng an d m a i nt a i n i ng t h e n eed ed data, a nd c ompl e t i n g an d r e v i e w in g c o lle c t i o n o f in f o r m at i o n. S e n d co mme nt s r e gar d i n g t h e b u r d e n est i m at e o ra n yo t h e raspect o f t h i s co l l e ct i o n o f i n f o r m at i o n , i n c lud i ng s ugges t i o n s f o r red u c i n g the burd e n to: D i r e c t o r , C o l l ect i o n s St r a t e g y D i vi s i o n , U. S. E nvi r o n me nt a l Pr ot ect i o n A g e n c y( m a i lco de 2822) , 1200Penn s ylva ni a Av e. , N. W . , W a s h i ngt o n , D . C . 20460- 0001. I n c l ud e t h e OM B nu m b er i d e nt i f i e d ab o v e i n a n yco rr e s p o n d e n ce. Do n o t s e n d t h e c ompl e t e d f o r m to th i s a d dr e s s . T h e actua l info r m a t ion o r fo r m s h oul d b e s u b m itte d i n acco r d a n ce w it h t h e i n st r u ct i o n s acco m p a nyi ng t h e f o r m , o r as spe cifi e d in th e c o r re s po nd i n g r e g u l at i o ns . b . N o . of T r a n s f or me r s a nd wt . ( k g) : b . N o . of T r a n s f or me r s a nd wt . ( k g) : c . A n y

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E P AF orm 7720-12 (06 / 02)

### Item-by-Item Instructions for Completing EPA Form 7720-12

Return completed form to: Fibers & Organics Branch (7404T) Office of Pollution Prevention & Toxics U.S. Environmental Protection Agency 1200 Pennsylvania Ave., N.W. Washington, DC 20460-0001 FAX – 202-566-0473 PCB Transformer means any transformer that contains 500 ppm or greater PCB dielectric. For PCB concentration assumptions applicable to transformers containing three pounds or more of fluid other than mineral oil, see 40 CFR 761.2. For provisions permitting reclassification of electrical equipment containing 500 ppm or greater PCBs to PCB-Contaminated Electrical Equipment, see 40 CFR 761.30(a) and (h). Type or print in black ink all items, except Item 3, “Certification.” If you must use additional sheets, indicate clearly the number of the item on the form to which the information on the separate sheet applies. Item 1 Company Name: Enter the name of the company which owns the equipment. Address: Enter the street, city, state, and zip code of the company. Contact Name and Phone Number: Enter the name and business telephone number of the person who should be contacted regarding information submitted on this form. Item 2a Location of PCB Transformers: Enter the address (street, city, state, and zip code) where the PCB Transformer(s) is located. Please note that the address you give must be a physical address, not a P.O. Box. Route numbers are acceptable provi ded they include enough specificity to assist emergency response personnel in determining the location of the transforme r(s). Item 2b Number (No.) of Transformers and weight (wt..): Enter the total number of PCB (500 ppm or greater) Transformers at this location (address) and the total weight (wt..) in kilograms (kg) of the PCB dielectric fluid in the transformer(s). Item 2c Any transformers containing flammable dielectric fluid: (Response optional) Circle yes or no if you have any knowledge that there are or are not transformers at this location (address) that contain flammable (see 40 CFR 261.21(a)(1) - Characteristics of Ignitability) dielectric fluid. ***Please note this form has been designed to accommodate companies submi tting registrations for multiple locations. However, companies with more than 4 locations may choose to submit an additional form(s) or an attachment(s). Item VII -- Certification: This certification must be signed by the owner, operator, or an authorized representative of the transformer owner or operator of the facility or property where the unit is located. An “authorized representative” is a perso n responsible for the overall operation of the facility (i.e., a plant manager or superintendent, or a person of equal responsibi l ity). All notifications must include this certification to be complete.

EPA Form 7720-12 Reverse (06/02) 

## No information on this form may be claimed as confiden tial.