VI. COPIES OF FORMS

A. NOTIFICATION FORM 2

B. DANGEROUS WASTE PERMIT FORMS FORMS 3 & 4

C. GENERATOR ANNUAL DANGEROUS WASTE REPORT FORM 4

D. TSD FACILITY ANNUAL REPORT/UNMANIFESTED WASTE REPORT FORM 5
ECY 0»5 INSTR..

REV. 8/82

NOTIFICATION

FORM 2
ECl.B·:zee.

INSTRUCTIONS FOR NOTIFICATION

PERSONS WHO DO NOT ALREADY HAVE AN EPA/STATE IDENTIFICATION NUMBER AND

EITHER THEY GENERATE, TRANSPORT, TRANSFER, TREAT, STORE, OR DISPOSE OF

DANGEROUS WASTE(S) DESIGNATED UNDER THE DANGEROUS WASTE REGULATIONS,

CHAPTER 173-303 WAC, MUST OBTAIN AN IDENTIFICATION NUMBER FROM THE DEPARTMENT OF ECOLOGY.

STEP 1-DETERMINE IF YOU HANDLE A DANGEROUS WASTE

CHECK TO SEE IF YOUR WASTE(S) MEET THE DESCRIPTIONS OF THE FOLLOWING

SECTIONS:

A) DISCARDED CHEMICAL PRODUCTS. WAC 173-303-081; OR

B) DANGEROUS WASTE SOURCES, WAC 173-303-082; OR

C) DANGEROUS WASTE MIXTURES, WAC 173-303-084; OR

D) DANGEROUS WASTE CHARACTERISTICS. WAC 173-303-090.

STEP 2-HOW TO GET AN EPA/STATE IDENTIFICATION NUMBER

COMPLETE THE FOLLOWING ON FORM 2:

A) NAME OF FACILITY

B) FACILITY MAILING ADDRESS

C) LOCATION OF FACILITY

D) FACILITY CONTACT

E) OWNERSHIP

F) TYPE OF DANGEROUS WASTE ACTIVITY

F-1) MODE OF TRANSPORTAnON

G) CERTIFICATION

H) WASTE IDENTIFICATION

H-1) DESCRIPTION OF WASTE (E.G. WASTE ACID; SPENT SOLVENTS)

H-2) DANGEROUS WASTE NUMBER (INCLUDE THE WASTE NUMBER FROM THE

LISTS AND CHARACTERISTICS, E.G., DOOl FOR IGNITABLE WASTES)

H-3) AMOUNT OF WASTE (ANNUAL)

H-4) UNIT OF MEASURE (P=POUNDS T=TONS K=KILOGRAMS: M=TONNES

[l,OOOKG»

I) FORMS REQUEST (CHECK ALL BOXES OF THOSE FORMS REQUIRED)
.-

\.' St~te of FACILITY 1.0. NUMBER

Wuhington

Dep.utment NOTIFICATION OF WIAI I I I I I I I I I of Ecology

DANGEROUS WASTE ACTIVITIES o RCRA/STATE o STATEONLY

FORM 2 DEPARTMENT USE ONLY

A. NAME OF FACILITY I

I I I I I I I I I ! I ! , : I

:

I i I I I I I i I , I

I I I I I I I I I I I. r I I I I , I I : I ! i

B. FACILITY MAILING ADDRESS .L. ---_.._-------_.--- --------_..._----,---. -._- ---------------

STREET OR P.O. BOX

I IJ-IUJ1.TI~r-T-~:'-I '~;-T-' ~~T-T _.r-T'-r!- .- .. •. -.. ;-_.O'··-t-- 'r .......r - . ;....r r'rJ--r'l-r- I . , , 1 __ __ ._. __ . __ , _. L_. I. __ ., . ..- -" ... __ I . . .. . .1. . _._ ....... _ __ ._

CITY OR TOWN STATE ZIP CODE

I I I I I i I I i , , I I --- , , I I I I I : r . I , , 1 i I

'1 ; i i j , i i , ,

C. LOCATION OF FACILITY

STREET OR ROUTE NUMBER

I I I I I I I I I I I I I I I I I I I I I I I I I

! I I I i I I I I I I I , i

CITY OR TOWN STATE ZIP CODE

I I I I I I I I I I I I I I I I I I I I I I I I !l m I I I I I I II

D. FACILITY CONTACT I NAME (last. first)

I I I I I I I I I I I I ! I \

I ! I I I I I I

I I I I I I I I I , I I i I j I

TITLE TELEPHONE

I I I I I I I I I I I I I I I I I ! I I I I I I ---'. I I I-I I I 1- , i I I I I

E. OWNERSHIP I - ..-

LEGAL OWNER OF FACILITY TYPE OF OWNERSHIP

I I I I , I I I I I I I I I I I II I I I I I I

I, F c Federal n N a Nonlederal I

I ! i

i

F. TYPE OF DANGEROUS WASTE ACTIVITY I

(Enter "X" In tha appropriate boxes)

o GENERATION o TRANSPORTATION o TRANSFER FACILITY o TREAT/STORE DISPOSE o UNDERGROUND INJECTION

(Complete F-I)

F-1. MODE OF TRANSPORTATION ,

, .____ .• _ _ L._~~~__ _ _ .. ___ --_._- ----_. - _.. ~----_.__._---_.--_..._--

o AIR o RAil o HIGHWAY o WATER o OTHER (specify)

G. CERTIFICATION !

,

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all

attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the

information, I believe that the submitted information is true, accurate, and complete. I am aware that there are significant

penalties for submitting false information, inclUding the possibility of fine and imprisonment.

SIGNATURE i NAME & OFFICIAL TITLE (type or print) DATE SIGNED

j

Eey 030-5

(COMPLETE REVERSE)

EClA .289- Page 1 012
: I

i I

H.

LII

I B

N I!

E A

WASTE IDENTIFICATION

H-1. DESCRIPTION OF WASTE 1

H-2.

DANGEROUS '

I WASTE NUMBER

I

H-3. AMOUNT

OF

WASTE (ANNUAL) 11

2 i ! I I I I

3

4

5

!r-r-"-----,-,--,--i 'i!I II I

1--+---------,-------1 ;' :;: Ii! I

...--+------------.---.-.._-.--- - ...-.----_.--._-----------h-----~___.____r-:---~,--t-;-+1-l--+-+-+-++--H

1'--'''''' ii'

8

7

i I I i I I I I I i ! i ;

I

I

1---+------,-----------.------------.------------'-"-J-';-,"T"-,--,--+--+--+-+--+--+--+--+--+--+-I--H

8

...--+------------------------------+--,---,--.,--+--.,-.,-.,-+-+-+-+-+-+-+-+-+-++--H

I

I 10

I---f----------------------------------+--,--,--~--......,-.,--r--+_+-+_+_+_+_+_+_+_++-t-I

11

r---f-----.---- ---------------,--- ...._---- .--- ._.... ------ "-'-'--'----.-r,-' r

I

:-"T-'-,---'-';-- - -.. - -+---+-+-++-H

13

14

I

15

I

i

COIIII£NTS (ENTER INFORMATION BY LINE NUMBER-SEE INSTRUCTIONS)

I. FORMS REQUEST (Ct'tECK THE BOX OF THOSE FOilM(S) REQUIRED AND INDICATE HOW MANY).

D NOTIFICATION FORM

D PART A PERMIT FORM FOR TSD FACILITIES

D GENERATOR ANNUAL DANGEROUS WASTE REPORT FORM

D TSD FACILITY ANNUAL DANGEROUS WASTE REPORT/UNMANIFESTED WASTE REPORT

D BIOLOGICAL TESTING PROCEDURES

D CHEMICAL TESTING PROCEDURES
· --_.

,

:(5)

scv 03l>-5 INSTR.

REV. 8/82

NOTIFICATION

FORM 2

Return Completed Form To:

DEPARTi\,IENT OF ECOLOGY

A ttn: Dangerous Waste Notifications

fvlail Stop PV-II

l"'lvlllpia. \\1/\ g3')04

.:.''''
~r.1 A .?fMI.

INSTRUCTIONS FOR NOTIFICATION

PERSONS WHO DO NOT ALREADY HAVE AN EPA/STATE IDENTIFICATION NUMBER AND

EITHER THEY GENERATE. TRANSPORT. TRANSFER. TREAT. STORE. OR DISPOSE OF

DANGEROUS WASTE(S) DESIGNATED UNDER THE DANGEROUS WASTE REGUl.ATIONS.

CHAPTER 17330J WAC, MUST OBTAIN .\N IDENTIFICATION NUMBER FROM THE DEPART

MENT OF ECOLOGY

STEP 1-DETERMINE IF YOU HANDLE A DANGEROUS WASTE

CHECK TO SEE IF YOUR WASTE(S) MEET THE DESCRIPTIONS OF THE FOLLOW!NG

SECTIONS.

A) DISCARDED CHEMICAL PRODUCTS, WAC 173·303·081, OR

B) DANGEROUS WASTE SOURCES, WAC 173·303·082; OR

C) DANGEROUS WASTE MIXTURES. WAC 173·303·084; OR

D) DANGEROUS WASTE CHARACTERISTICS, WAC 173·303·090

STEP 2-HOW TO GET AN EPA/STATE IDENTIFICATION NUMBER

:;OMPLETE THE FOLLOWING ON FORM 2:

A) NAME OF FACILITY

B) FACILITY MAILING ADDRESS

C) LOCATION OF FACILITY (enter 'S.~\ME' if ident ic.i l to mailing address)

Be sure to enter the eLl' '.;TY in which f aci li tv is located.

D) FACILITY CONTACT

E) \)WNERSHIP

Fi TYPE OF DANGEROUS WAsrE ACTIVI~Y

F 1) MODE OF TRANSPORTATION-(Complete this section only if you wi l! be

transporting Wc}QC o l f -si te and rnar kcd

G) CERTIFICAnON tr ansporat ion in P:!rt F)

H) WASTE IDENTIFICATION

H·') DESCRIPTION OF WASTE (EG WASTE ACID: SPENT SOLVENTS)

H·2) DANGEROUS WASTE NUMBER (INCLUDE THE W.t\STE NUMBER FROM T~E

LISTS AND CHARACTERISTICS. E.G. 0001 FOR IGNITABLE WASTES)

H·3) A,MOUNT OF WASTE (ANNUAL) Estimated or Ac tual if ava ilablc

H·4) UNIT OF MEASURE (P-=POUNDS : T=TONS K=KILOGRAMS: M=TONNES

[ 1.000KGJ)

NOTE: Do not use units of volume, convert to units of Weight

I) FORMS REQUEST (CHECK ALL BOXES OF THOSE FORMS REQUIRED)

!~.',.;L-1

- "<.
"'~-----~--------------------r-----------.., Stateot

Wuhlngton

Oepmmenl

ot Ecology

MS-PV-Il

Olympia, WA 985C 4

FORM 2

NOTIFICATION OF

DANGEROUS WASTE ACTIVITIES

FACILITY 1.0. NUMBER

wi A! Im--,-,uT -lLl. c--, -L-_ . ._I-_J..-.1._..

o RCRA/STATE 0 STATE ONLY

DEPARTMENT USE ONLY

A. NAME OF FACILITY !

f--.-------....-----',---.---.------.------------.-----.-..---------...-------._---- -------- ..-.

f--.,---;-' -:--..- -·----------·-·.,--Ti-- "'---,-,---~._.---'_.-~..---,-.,----.--.. ._u~ ._,----;-·--~i--..·~--I--·r--l---·

I j 1 ' ! : :! .:! I I : : I ; .' . i ! I I I

B. FACILITY MAILING ADDRESS

f- ....•

f-L :

STREET OR P.O BOX

--.-...- .-------.. ---,--- T"--~·-,

. __ ; _•. ..00_._ • __: iii 1•• _ J. , __•

1--E. __OWNERSHIP .. ....:.-.L...... I ... . . . ---.----------.-- __. ...._.... __._.. ..__ ......

-r-:•...,

·~0%

CITY OR TOWN ----..--.. ..- - ----. --;-'-'-1'-'-- -

I ' :

C, LOCATION OF FACILITY, f----.

CITY OR TOWN

I I T i I I ! -"1-' I I !

D. FACILITY CONTACT I NAME (last, fir.I)

I I I I I I

i. _1.._ .! _ 1.....1.. ..J ._, 1 .;.J_J__.: __

STATE

I i I

i ._. •.1- 1._

! ! l-r-- , , ' I L_. L. 1. r .

TYPE OF OWNERSHIP

r

---j F = Foderal ; N - Nonfederal

F. TYPE OF DANGEROUS WASTE ACTIVITY ..:.....:-----------'-------------_._----_._---------_._------

(Enter "X" In Ihe appropriate boxe.)

o GENERATION 0 TRANSPORTATlON

(Complet. F·1)

o TRANSFER FACILITY o TREAT/STORE DISPOSE o UNDERGROUND INJECTION

F·1. MODE OF TRANSPORTATION J r---'--'---' -- ---------------

OAIR o RAIL o HIGHWAY o WATER o OTHER (specify)

G, CERTIFICATION _.- - . --- -... -- ----------

'certify under penalty of law that I have personally examined and am familiar with the information submitted in this and ett

attached documents, and that baaed on my inquiry of those individuals immediately responsible for obtaining the

information, I believe that the submitted information is true, accurate, and comotete t am aware that there are significant

penalties for submitting false information, including the possibility at tine and imprisonment.

"'-_....-.__...

SIONATURE

fCY 030-5

ECLA -280-

! NAME & OFFICIAL TITLE (tvpe or print)

(COMPLETE REVERSE)

DArE SIGNED

Psge 1012
r"'

.!t•••••

H-3. AMOUNT ~.~'! \

OF ! v'CS i _ WASTE (ANNUAl.> ! t::"-

Est irna teo or Actuag~

H-2. {

DANGEROUS

WASTE NUMBER

H-l. DESCRIPTION OF WASTE

.~--------------------------------_._;-----_._---._---------------' H. WASTE IDENTIFICATION

l Ell I 8

I« f

E R I

r'~

. ~~~:;~- I , I I

------_..__._._-------_.

p' - ••.•-r--.~

--- - .

; : ! ! ! Ii :

:! -- -_____ n _.. ..-._n .. - n ~~=_:-~-~ ::--=~~:~~:-_:::=- ~r-iih

_·-t···_·--.-.--.....---..---------------- _.-...---..--..--.-~----------- ..---.--.--------...-. -- ..-.--.. ,

-4 1i .. .~-! .. -i~--I- 5:I ~·-··f6;, , - - .... • _._- - -- ....-.---- +-r'-+-

7 i ......-.--.: 1

... j .. -.... "-'-'. .... .. ; -i-d)-

,~:=~--:~::~==~--~-==--=====-==:=--- '-~~~~:=~:=-==---:-:~-H t I !

10 -,---.----- If, I -~~! .. --.-...- -.. - -.--....---- ---.. - - ... --..---'---~=-~- ..~~--==:.--~:---~- ..----.---..-'-':-~-~-':i'fl

-.-~-- ..- " --..- -.-------.---- -.----..--_.---. -_ ..- '-- ---.-. - - - -.-..--.---.------ '- --- .-------. _..-.- .-. ---"---'~--+-+-i--H 1 ._ : i! I

8=:::-==:-----------.------.----- :;-,------:..-_..--, .__n_~, : " :

15 i

COMMENTS (ENTER INFORMATION BY LINE NUMBER-SEE INSTRUCTIONS)

~-_ .. ---.-.-.---.-.--.--------.--.-- -------------------------------.--------.------------1

I. F.OR_MS_REOU.~S_T_ (.c~ECK THE BOX 0"-_THOS~.!~,!~_<:!)_ ~~().':l!.'!~D~ND_~~A__r:~.!:l~~~~)~. . . __ .__. ._ ...._. __ .__ .. __.. .__--dI

o NOTIFICATION >=ORM I

o PART A PERMIT FORM FOR TSD FACILITIES

o GENERATOR ANNUAL DANGEROUS WAS-;E REPORT FORM

o TSD FACILITY ANNUAL DANGEROUS WASTE REPORT/UNMANIFESTED WASTE REPORT

o BIOLOGICAL TESTING PROCEDURES V'

o CHEMICAL TESTING PROCEDURES
I ...?"'i'~

V

ECY 030-31 INSTR.

REV. 8/82

PART A

DANGEROUS WASTE PERMIT FORMS

(FORMS 1 and 3)
Permll Appllcallon Process

WASHINGTON STATE

DANGEROUS WASTE PERMIT

GENERAL INFORMATION

Confldenllal Informallon (continued)

~~

;iii

There are two carts to a Dangerous Waste Perrmt Application-Part A and Part

~. Part A consists of Form 1 and Form 3. Part B requires detailed

slle-specific intormation such as geologic, hydrologic, and engineering deta.

WAC 173-303-800 specifies the information that will be required from

dangerous waste management facilities in Part B.

DperaUon Durtng Inlertm Sialus

Psrt A of the permit application defines the processes to be used for treatment,

slorage. and disposal of dsngerous wasfes; the design capacity of such processes; and the specific dsngerous wastes to be hendled at e fecili.y during

the interim status period. Once Pert A is submilled to the Depsrtment of

Ecology, chsnges in the dangerous waa'ea handled, changes in design

capacities, changes in processes, and changes in ownership or operational

control at a facility during the interim status period msy only be mede in secordsnce with the procedures in WAC 173-303-820. Chsnges in quantity of weste

hsndled at a fscility during interim stetus can be mede without submilling e

revised Part A provided the quantity does not exceed 'he design cepecities of

the processes specified in Psrt A of the permit spplicetion. Failure to turnish all

informstion required to process a permit spplication is grounds for termination

of sn interim status permit.

Confldenllsl Informallon

All information aubmilled in thie form will be eubject to public disclosure, to the

extent provided by RCRA and the Freedom of Information Act, 5 U.S.C. Section

552, and EPA's Business Confidentiality Regulations, 40 CFR Part 2 (see

especially 40 CFR 2.305), and will be subject to the State of Washington Public

Records Act chapter 42.17 RCW and chapter 43.21A-I80 RCW. Persons filing

this form may make claims of confidentiality. Such claims must be cleerly indicated by msrking "confidentiel" on the specific information on the form for

which confidential treatment is requested or on any allschments, and must be

accompanied. at the time of filing. by e wrillen substantietion of the claim. by

answering the following questions:

ECY 030-31 fNSTR.

Eel' -273-

A. Which portions of the information do you claim ere entitled to confidential

treatment?

B. For how long rs confidential treatment desired for this information?

C. What measures have you taken to guard against undesired disclosure of

the information '0 others?

D. To what extent has the information been disclosed to others, and what

precautions have been taken in connection with that disclosure?

E. Has the Department of Ecology. EPA or any other Federal or Slate agency

made a pertinent confidentiality determinetion? II so, what would tho88 harmful

effects be and why should they be viewed as aubstantial? Explain the ceuaal

relationahip between disclosure and the harmful effects.

If no claim of confidentielity or no substsntietion sccompanies the informetion

when it is submilled. EPA or the depertment msy make the information evailable

to the public without further notice to the submiller.

Deflnilions

Terms used in these instructions and in this lorm are defined in the Definilions

secllon of the Dangerous Waste Regulation, chapter 173-303 WAC.
FORM 1-INSTRUCTIONS

ThIs form must be completed by all applicants. Section VII-C

Completing This Form

Enter the appropriate letter to Indicate the legal status of the operator of Ihe

facility Indicate "public" for a facility aolely owned by local government(s) such

as a city. town. coun1y, parish. ate.

Please type or print. If you print. place each character between the marks.

Abbreviete if necessary to stay within the number of characters allowed for

each item. Use one space for breaks between words. but not tor punctuation

mar1<s unless they are needed to clarify your response.

Sections VII-D-H

Enter the telephone number and address of the operator identified in Item VII-A.

Section VIII

section I Indicate whether the facility is loco led on Indian lands

section II

section VI

section III

Enter the lacility's official or legal name. Do not use a colloquial name.

AREA SERVED

Ariz. Callt., : _ _'. Ida~.o,

Nev.. Oreg .. Wash.. American

Samoa. Guam. and trust

Territories

U.S.G.S. OFFICES

Western Mapping Center

National Cartographic Information

Center

U.S.G.S.

345 Middlefield Road

Menlo Park. Ca. 94025

Phone No. (415) 323·81 11

Section IX

Provide B topographic map ot maps of the sr ea odondlng 8t leo At to one mile

beycnd the property bounnunes of the faCility whtt::h· cte artv show tho 'ollowing:

Tho leIJal boundaries of lho IOClilty;

The location and aerial number of each of your a,osting and proposed intake

and discharge structures:

All hazardous waste management facilities;

Each well where you inject f1uida underground; and

All springs and surface water bodies in the area. plus sll drinking wster wells

within V. mile of the facility which are identified in the public record or otherwise known to you.

" an intake or discharge structure, hazardous waste disposal site. or injection

well associated with the facility is located more than one mile from the plant,

include it on the map. if possible. " not. attach additional sheets describing the

location of lho structure. disposal site. or well. and identify the U.S. Geological

Survey (or other) map corresponding to the location.

On each map. include the map scale. a meridian arrow showing north, and

latitude and longitude at the nearest whole second. On all maps of rivers, show

the direction of the current. and in tidal waters. show the directions of the ebb

and flow tides. Use a 7 -'~ minute series map pubtishec by tho U.S. Geologicsl

Survey, which may be obtained through the U.S. Geological Survey Offices

listed below. If a 7 _.!z minuto serioa mop has not been published for your facili·

ty site. then you may use a 15 minute series map from the U.S. Geological

Survey. " neither a 7-I> nor 15 minute series map has been published for your

fscility site. use e ptat mop or other appropriate map. including all the reo

queated informstion; in this case, briefly describe land uses in the map sroa

(e.g" residentisl, commercial).

You may trace your map from 8 geological survey chart, or other map meeting

the above specifications. If you do. your map should boar 8 note showing tho

number or title of the map or chart it was treceo from. Include the names of

nearby towns. water bodies. and prominent POlOtS.

Southwest Regional Office

7272 Cleanwater Lane

Olympia, Washington 98504

Tel: 206-753-2353

Northwest Regionsl Office

4350 - l50th NE

Redmond. WaShington 98052

Tsl: 206-885- 1900

section V

Give the address or location 01 the facility identified in Section III of this form. If

the fecility tacxa a street neme or route number. give the most accurate alter'

nlltive geographic information (e.g.• section number or quarter section number

from county records or at intersection 01 Rts. 425 and 22).

Space is provided at the upper right hand corner of Form 1 for ins ertron of your

EPA/Stete identification number. If you have an ell.ISling facility, antor your identificatton numbor. If you don't have an EPA, State ldentific:ation numbor. please

contact the Department at Ecology (206) 459·6303 and one will be provrcoo for

you. If your faCility is new (not yet c onatructedj. leave Ihis it ern blunk.

section IV

Give the complete mailing address 01 the office where corre apondance should

be sent. This often is not the address used to designate the location of the

facility or activity.

Give the name. title. and work telephone number of a person who is thoroughly

familiar with the operation of the facility and with the facts reported in this application snd who can be contacted if necessary.

Llet. in deacendlng order of significance. the four 4-dlgit standard industrial

classiflcetlon (SIC) codes which best describe your fecility in terms of the prtnclpsl products or services you produce or provide. Also. spoclfy each

classification in words. These classifications may differ from the SIC codes

describing the operation generating tho dangerous wastes.

SIC code numbers are descriptions which may be found in the "Standard tndustrial Cisasification Manual" prepared by the Executive Office of the Presi·

dent, Office of Management and Budget, which is available from the Government Printin\; Offics. Washington, D.C. Use the current edition 01 the manual. If

you have any queaticna concerning thP. appropriate SIC code for your facility,

contact your Department of Ecology Regional office (see Table 1).

Table 1. Depanment of Ecology RegIOnal Offices

Eastern Regional Office

East 103 Indiana

Spokane, Washington 99207

Tel: 509-458-2926

Central Regional Ottice

3601 West Washington

Yakima, Washinglon 98903

Tel: 509-575-2490

Section X

Briefly describe the nature of your business (e.g., pr oouct s produced or services

provided).

section VII-A

Give the name. as ;1 is legally referred to, of the person. firm. public ~rganlz8'

tion. or sny other entity which operstes the facility described in this application.

This mey or may not be the same name aa the facility. The operator of tho

facility is the legal entity which controls the raciurvs operation rather than 1t~e

plant or site manager, Do r'ot use a colloquial name.

Section VII-B

Indlcete whether the entity which operates the facility also owns it by marking

the appropriate box.

Section XI

For a corporation, by 8 principal. executive officer of at least the level of vice

preaident.

For partnership or sale proprietorship. by 8 gallardl partner or the proprietor.

respoctively; or

For a municipality, srere, Federal. or othor public facility. by elthor B principal

executive officer or ranking elected offiCial.

ECY 030-31 IHSTR.

ECL2 -213-
J

FORM

1

~tateor

Washington

Department

ontology

I. EPA/STATE 1.0. NUMBER

WASHINGTON STATE

DANGEROUS WASTE PERMIT GENERAL INFORMATION

(Resd "Form I tnetructions" be/ore slarting)

U. NAill! OF FACILITY

I I I I I I 1 I I I I I I I I I I I I I I ,

lit. FACILITY CONTACT

IV. FACILITY MAILING ADDRESS

I I

C.STATE D. ZIP CODE

B. PHONE (area code & no.)

i I : 1 I I I I I 1 , I I

"

I I

" ! 1 ! r I 1

i r

I ! ! I i I I

!

I ! I ! I t ! !

B. CITY OR TOWN

I ! I , t ,!

i I I

A. STREET OR P.O. BOX

H

"

V. FACILITY LOCATION

A. STREET. ROUTE NO. OR OTHER SPECIFIC IDENTIFIER I

H -'---'-_-".......---L---'.-'--._'...J J.......1.. _J._ .J L_-'•. _.L_-, --L__--'----L...-..<_.J._-'-'--.L.....J---'--L._~ t±:..------------ ..... -..-._--.------.----.. --------·-r-------· B. COUNTY NAME

f-,--,-r-T-T I I I T I I 1 I I-,'-'--r-r-,--" i ; I .

D.STATE E.lIPCODE F. COUNTY CODE

(ilknown) , , i

I I

B. SECOND

I I I I (specify)

D. FOURTH

H (specify)

I -,---r i I I I 1 1 I 1

, ! r ! r I 1 [ r r I

C. CITY OR TOWN

C. THIRD

VII. OPERATOR INFORMATION

, I I I I (splJCify)

A. NAME t=-r--T-·r-,-.-r-,- r~--,,-.,-1'....-,--,.....,-,-,-,-.,------,-

H I I I (specify)

-;..... . ;".,';.~_

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<; IV. SIC CODES (4-digit, in order of priority)

A. FIRST

E. STREET OR P.O. BOX

I I I

F. CITY OR TOWN

1 1

G.STATE

iI I I

H. ZIP CODE VIII. INDIAN LAND

Is the facility located on Indian lands?

DYES D NO

COMPLETE BACK PAGE

'~Y030-31

Eel" ·219,
IX. MAl» ------------------------------------------------------ Attach to this application a topographic map of the area extending to at least one mile beyond property boundaries. The map must show If) -

outline of the facility, the location of each of its existing and proposed intake and discharge structures. each of its hazardous waste treatment, ':,,:.;~.../

storage, or disposal facilities, and each weI! where it injects fluids undergound. Include all springs. rivers and other surtace water bodies in the

map ares. See instructions for precise requirements.

X. NATURE OF BUSINESS (provide a brief description)

.,~,

"0;iJ

XI. CERTIFICATION (see instructions! . -1

I certify under penalty 'ot law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of tnose persons immediately responsible for obtaining the information contained in the application, t

believe that the information is true, accurate and complete. t am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

A. NAME & OFFICIAL TITLE (type 0, p"nt) B. SIGNA TURE

------------------------------------------------------------.----------------i C. DATE SIGNED

ECY 030-31 Reverse

ECL5 -218-
----------------,-----------------

FORM 3-INSTRUCTIONS

Completing This Form

Please type or print. If you print place each character between the

marks. Abbreviate if necessary to stay within fhe number of characters

allowed for each item. Use one space for breaks between words, but

not for punctuation marks unless they are needed to clarify your

response.

Section I

Existing dangerous waste management facilities should enter their

EPA/STATE Identification Number (if known). New facilities should

leave this item blank.

Section II

A. FIRST APPLICATION. If this is the first application that is being filed

for the facility place an"X" in either the Existing Facility box or the New

Facility box.

t. EXISTING FACILITY. Existing facilities are:

a. Those facilities which received hazardous waste for treatment, storage, and/or disposal on or before November 19,

1980; or

b. Those facilities for which construction had commenced on

or before November 15, 1980. Construction had "commenced"

only II:

(1) The owner or operator had obtained all necessary

Federal, State, and local preconstruction approvals or permits; and

(2-a) A continuous physical, on-site construction

program had begun (facility design or other preliminary

non-physical and non-site specific preparatory

activities do not constitute an on-site construction

program), or

(z-b) The owner or operator had entered into contractual

obligations (options to purchase or contrects for feasibility,

engineering, and design studies do not constitute contractual obligations) which could not be cancelled or

modified without substantial loss. Generally, a loss is

deemed substantial if the amount an owner or operator

must pay to cancel construction agreements or stop construction exceeds 10"10 of the total project cost.

EXISTING FACiliTY DATE. If the Existing Facility box is mark·

ed, enter the date dangerous waste operations began (i.e., the

date the facility began freating, storing, or disposing of

hazardous waste) or the date construction commenced,

2. NEW FACILITY. New facilities are all facilities for which construction commenced, or will commence, after November 19:

t980.

NEW FACILlTY.DATE. If the New Facility box is marked, enter

the date that operation began or is expected to begin.

B. REVISED APPLICATION. If this is a subsequent application that is

being filed to amend data filed in a previous application. place an "X" in

the appropriate box to indicate whether the facility has interim status or

a permit.

1. FACILITY HAS AN INTERIM STATUS PERMIT. Place an "X" in

this box if this is a revised application to make changes at a facili·

ty during the interim status period.

2. FACILITY HAS A FINAL PERMIT. Place an "X" in this box if this

is a revised application to make changes at a facility for which a

permit has been issued.

(NOTE; When submitting a revised application, applicants must

resubmit in their entirety each item on the application for which

changes are requested. tn addition, Items land IX (and Item X if applicable] must be completed. It is not necessary to resubmit information for other items that wilt not change).

ECY~31INSTR.Form 3

ECl3A ·21'·

Section III

The information in Section III describes all the processes that will be

used to treat, store, or dispose of dangerous waste at the facility. The

design capacity of each process must be provided as part of the

description. The design capacrtv of injection wells and landfills at existing facilities should be measured as the remaining, unused capactty. See the form for the detailed instructions to Section III.

SectlonlV

The information in Section IV describes all tho dangerous wastes that

will be treated. stored. or disposed at the facility. In addition. the processes that will be used 10 treat. store, or dispose of each waste and

the estimated annuai ouantttv of each wasle must be provided. See

the form for the derarleo .nstrucuons to Section IV.

Section V

All existing facilities must include a drawing showing the general

layout of the facility. This drawing should be approximately to scale

and fit in the space provided on the form. This drawing should show

the following:

The property boundaries of the facility:

The areas occupied by all storage, trealment, or disposal operations that will be used during interim status;

The name of each operation. (Example-multiple hearth incineretor, drum storage area, etc.);

Areas of past storage, treatment. or disposal operations;

Areas of future storage. treatment, or disposal operations; and

The approximate dimensions of the property boundaries and all

storage, treatment. and disposal areas.

Section VI

All existing facilities must include photographs that clearly delineate

all existing structures; all existing areas for storing, treating, or

disposing of hazardous waste; and all known sites of future storage,

treatment, or disposar operations. Photographs may be color or black

and white, ground-i .vel or aerial. Indicate the date the photograph

was taken on the back 0f each photograph.

Section VII

Enter the latitude and longitude of the facility in degrees, minutes, and

seconds. For larger facilities, enter the latitude and longitude at the

approximate mid-point of the facility, You may use the map you provided for Section IX of Form 1 to determine latitude and longitude.

Latitude and longitude information is also available from Regional Offices of t"e U.S. Department :If Interior, Geological Survey and from

State agencies such as the Department of Natural Resources.

Section VIII

See the form for the instructions to Section VIII.

Section IX and Section X

All facility owners must sign Section IX. If the facility will be operated

by someone other than the owner, then the operator must sign Seclion

X. Federal regulations require the certification to be signed as follows:

A. For a corporation, by a principal executive officer at least the

level of vice president;

B. For a partnership or sole proprietorship, by a general partner

or the proprietor. respectively; or

C. For a municipality, State, Federal. or other public facility, by

either a principal executive officer or ranking elected Official.

C')

'~~-!-".:.-'

. "

~'
t1aI:M prau Of type 1tI I". unanaau .retla oruy

(tm-it1 ,_,,,.apaced lor eltl. /yIN, i.•..•2 char,c/en/lnc/t).

FOAM

3 DANGEROUS WASTE PERMIT APPLICATION

I. EPA/STATE I.D. NUMBER

I I I I I I I I I I I

:::-: FOR OFFICIAL USE ONLY

~:;~J~ I Dr~;,e RECE.'VED I COMMENTS -...:."

W I

I I r I , ! I

I I, II L,I

II. FIRST OR REVISED APPLICATION

Piece en "X" in the appropriate box in A or B below (mark one box only) '0 mdicate whether thia ia the firat epplication you are submitting for your facility or a reviaed applicetlon.1f thla

Ie your tlral application and you already know your facllity'a EPA I STATE I.D. Number. or if 'hla la a revlaed application. enter your facility'a EPA I STATE I.D. Number In Section I above.

T fiRST-APpLICATION (plsce an~ ..x.. "below 5ric{prtiviiiethe spp;·oprlstii date) -

o 1. EXlSTlNG FACILITY (See Instructions for definition of "9/(/Stln(J" facility

CompletB/fem below.)

I

~~~,' I . ! I ------~

rn! DE I YR.. 1. . I : I I: ,r-i ,---

FOR EXISTING FACILITIES. PROVIDE THEDATE (mo. aev. & yr)

OPERATION BEGAN OR1liE DATE CONSTRUCTION COMMENCED

(use the boxes to the left)

Q 2. NEW FACILITY (Complete item below.)

FORNEWFAClUTIES.

PROVIDE 1liE DATE (mo.. day, & yr.) OPERAnON BEGAN OR IS .

EXPECTED TOBEGIN

B. REVISED APPlICAnON (place an "X" below and comptete Sec/Ion I above)

o I. FACILITY HAS AN INTERIM STATUS PERMIT o 2. FACILITY HASAFINAL PERMIT

III. PROCESSES - CODES AND DESIGN CAPACITIES

A. PROCESS CODE - Enter the coda from the list of process codes below that best describes each process to be usad a/the facility. Ten lines are provided for entering codes. II more

lines ara needed, enter the code(s) in the space provided. " a process will be used that is not included in the list of codes below. then describe the proceaa (including its deaign

capacity) in the space provided on the (Section II/-C).

B. PROCESS DESIGN CAPACITY - For each code entered in column A enter the capacity 01 the precess.

1. AMOUNT - Enter the amount.

2. UNIT OF MEASURE - For each smount entered in column B( 1), enter the code from the list of unit measure codes below that deacribes the unit of measure uaed. Only the unlta of

measure that are listed below should be used.

PROCESS

PR~

CESS

CODE

APPROPRIATE UNITS OF

MEASURE FOR PROCESS

DESIGN CAPACITY PROCESS

PR~

CESS

CODE

APPROPRIATE UNITS OF

MEASURE FOR PROCESS

DESIGN CAPACITY

UNITOF MEASURE

..

-::£~';1

.Storage:

CONTAINER (barrel, drum. erc.)

TANK

WASTE PILE

SURFACEIMPOUNDME~T

DlaPOH':

INJECTION WELL

LANDFILL

LAND APPLICATION

OCEAN DISPOSAL

SURFACE IMPOUNDMENT

UNITOF MEASURE

SOl

S02

S03

S04

DBO

081

082

083

084

UNITOF

MEASURE

CODE

GAllONS OR LITERS

GAllONS OR LITERS

CUBIC YARDS OR

CUBIC METERS

GALLONS OR LITERS

GALLONS OR LITERS

e~u~l~~~~n~~~r~~~~e thst

d8(Jth alone toot}

OR HECTARE-METER

ACRES OR HECTARES

GALLONS PER DAY OR

LITERS PER DAY

GALLONS OR LITERS

UN'T OF MEASURE

Trestment:

TANK

SURFACE IMPOUNDMENT

INCINERATOR

OTHER (Use for physical. chemical,

thermal or biological treatment

processes not occurring in tanks,

surlace Impoundments or incinerators. Deacribe the processes in

the space provided; Section III-C.)

UNITOF

MEASURE

CODE

TOI

TO?

',03

T04

GALLONS PER DAY OR

LITERS PER DAY

GALLONS PER DAY OR

LITERS PER DAY

TONS PER HOUR OR , x.

METRIC TONS PER HOUR;

GALLONS PER HOUR OR

LITERS PER HOUR

GALLONS PER DAY OR

LITERS PER DAY

UNITOF

MEASURE CODE

GALLONS . LITERS . CUBIC YARDS . CUBIC METERS .. GALLONS PERDAYG

... L

....... Y

. C

.. U

LITERS PERDAY . TONSPERHOUR

METRIC TONS PERHOUR . GALLONS PERHOUR .. LITERS PERHOUR ..

.. .. vD

w

E

.H

ACRE·FEET

HECTARE·METER ACRES

HECTARES

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

.............. F

.. B ........... 0

B. PROCESS DESIGN CAPACITY

FOR

OFFICIAL

USE

ONLY

1. AMOUNT

(speedy)

2. UNIT

OF MEASURE

(enter

cods)

FOR

OFFICIAL

USE

ONLY

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20

600

i

X-2 T 0 J

X-I S 0

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i j" I I! 8!! ! ! j !:

4 I I 10 I--

ECl38 -300- Eey 030-31 Form 3 Rev, 2/84 PAGE 1 OF5 CONTINUE ON REVERSE
>ntinued Irom the Iront.

III. PROCESSES (continued)

C. SPACE- FOR ADDITIONAL PROCESS CODES OR FOR DESCRIBING OTHER PROCESS (code "T04"). FOR EACH PROCESS ENTERED HERE INCLuDE DESIGN CAPACITY.

IV. DESCRIPTION OF DANGEROUS WASTES

A. DANGEROUS WASTE NUMBER - Enter the four digit number from Chapter 173-303 WAC for each listed dangerous waste you will handle. If you handle

dangerous wastes which are not listed in Chapter 173-303 WAC, enter the four digit number(s) that describes the characteristics andlor the toxic contaminants of those dsngerous wastes.

B. ESTIMATED ANNUAL QUANTITY - For each listed waste entered in column A estimate the quantity of that waste that will be handled on an annual basis.

For each characteristic or toxic contaminant entered in column A estimate the total annual quantity of all the non-listed waste(s) thaI will be handled which

possess tnat characteristic or contaminant.

C. UNIT OF MEASURE - For each quantity entered in column B enter the unit of measure code. Units of measure which must be used and the appropriate codes

are:

ENGLISH UNIT OF MEASURE CODE METRIC UNIT OF MEASURE CODE

POUNDS. . . . . . . . . . .. . . . .. . P KILOGRAMS. . . K

TONS. . . . . .. .... . . . . . . .. . . . T METRIC TONS. . . . . .. . M

II lacllity records use any other unit of maasure lor quantity, the units 01 measure must be converted into one 01 the required units of meaaure taking into sccount the appropriate density or specilic gravity 01the waate.

D, PROCESSES

1. PROCESS CODES:

For lIated dangeroua waate: For each lIated dangerous waste entered in column A select tha coders) Irom the list of proceaa codes contained in Section III to indicate how the

waate will be stored. treated, endlor disposed of at the facility.

FOI' non-listed dangeroua waatea: For each characteriatic or toxic contaminant entered in Column A, select the c~de(s) from the list of process codes contained in Section III

10 indicate all the processes that will bo used to store. treat. and lor dispose of all the non-listed dangerous waate. 'hot posseaathat characteristic or toxic contaminant.

Note: Four spaces are provided for antering procesa codes. If more are needed: (1) Enter the first three as described above; (2) Enter "000" in the extreme right box of Item

IV-D( I): and (3) Enter in the space provided on page 4. the line number and the additional codera).

2. PROCESS DESCRIPTION: It a code is not liated for e process that will be used. deacribe the process in the space provrded on the form.

NOTE: DANGEROUS WASTES DESCRIBED BY MORE THAN ONE DANGEROUS WASTE NUMBER - Dangerous wastes thst cen be described by more thsn one Waste

Number shalt be described on the lorm as foltows:

1. Select one of the DAngerous Weste Numbers and enter it in column A. On the same line complete columns B. C. and 0 by estimating the total annual quantity of the

waste and describing all the processes to be used to treat. store. and zor dispose of the waste.

2. In column A of the next line enter Ihe other Dengerous Waste Number that can be used to describe the waste. In column 0(2) on that line enter "included with above" .

and make no other entries on that line. .

3. Repest atep 2 for each other Dangerous Waste Number thst can be used to describe the dangeroua waste.

EXAMPLE FOR COMPLETING SECTION IV (shown in line numbers X· t. X·2. X'3, and X-4 below) - A fscility will treat and dispose of an estimated 900 pounds per year of chrome ahavings from leather tanning and finishing operalion. In addition, the facility will treat and dispose of three non-listed wastes. Two wastes are corrosive only and there will be an eatimated

200 pounda per year of each waste. The other wsste ia corrosive and ignitable and there will be an estimated 100 pounds per yesr of that waste. Treatment will be in an incin.,ator and

dispoaal will be in a landfill.

X-J D 0 0 I

, !

X-I K 0 Sl4i I .

I I

X-2 D 0 0 i21

1. PROCESS CODES

(enter)

2. PROCESS DESCRIPTION

(it B code ;5 not enrered in O(OJ

I

i

D. PROCESSES

I

I I

I I

I ,

, I

I I I

I

I ,

;p 8 0 ! I I!

UJ 8 0 I

, I I I

T 0 3 D 8 0

T 0 3 I

i I I

iT 0 3

I

p

C. UN'T

I O~~REt

I,! (enter

code)

I

I

100

900

400

B. ESTIMATED ANNUAL

QUANTITY OF WASTE

A I

DANGEROUS I

WASTE NO. I'

(6nter code)

L

I N

,NO

'E

X-4 D 0 0 2

I I

T 0 J

I I

D 8 0

I I I f

included with above

ECL3C ·271· ECY 0»31 Form 3 PAGE 2 OF 5 CONTINUE ON PAGE 3
Continued trpm page 2. .

NOTE' Photocopy this page before completing if you have mora than 26 wastas to list

I

1.0.NUMBER(anter from paga I)

I I ! I I I I I

DESCRIPTION OF DANGEROUS WASTES (continued)

r;

'~IV.------------1---------------------------------------4

2. PROCESS DESCRIPTION

(if a code IS nol entsred inOf')

O. PROCESSES

._-,-------_._--------------_._------_._--

1. PROCESS CODES

(enter)

B. ESTIMATED ANNUAL

QUANTITY OF WASTE

3

L A. II IC. UNIT I

IN D~~~~ ·~~~I~---------------------------------~ NO I SURE

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ECl30 ·271· ECY~31Fonn3 PAGE 3_0F 5

(enter "A", "S". Ole" etc. behind the "3" to identify photocopitld psass)

CONTINUEON REVERSE
I

I

Continued from the Iront

IV. DESCRIPTION OF DANGEROUS WASTES (continued)

c

E. USE THIS SPACE TO LIST ADOITIONAL PROCESS CODES FROM SECTION 0(1) ON PAGE 3.

,

-

'-'.-;.;;

i

I

i

I

V. FACILITY DRAWING

All existing facilities must include in the space provided on page 5 a scale drawing of the facility (see tnstructtoo« (or more de teit).

VI. PHOTOGRAPHS

All existing facilitiea must include photographa (eeriel or ground-level) that clearly delineste sll existing structures: existing storace. treatment end disposal ereas: and

sites of future storage, treatment or disposal ereas (see instructions for more deteit).

VII. FACILITY GEOGRAPHIC LOCATION -._._-------- ,----- _.-_. -~..._- ------------ ... ~. LATITUDE (degrees, minutes. & seconds) LONGITUDE (degrees, minutes. & seconds)

~~~~'::~:; WWI I I I I I I IU-Ji I I I ,~

I

I

I

I

I VI1I. FACILITY OWNER

0 I A. If the facility owner is also the facility opere.or as listed in Section VII on Form t , "General Information", place an "X" in the box to the left and skip tc Section IX below.

B. lithe facility owner ia not the facili.y operator as liated in Section VII on Form t, complete the following items:

1. NAME OF FACILITY'S LEGAL OWNER 2. PHONE NO. (area code & no.) , , , , , I , i i 1.\ I I 1·1 I I I i , I ! I ! ! ! ! I I ! ! ! , ! { , ! !

3. STREET OR P.O. BOX ! 4. CITY OR TOWN 15. ST.! 6. ZIP CODE , , ,--,- !

I ! : i I i I ! I I ! ,

j I I I ; , , I ! I

IX. OWNER CERTIFICATION

I certify under penalty of law that I have personally examined and am familiaf with the information submitted in this and al/ attached

documents. and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the

submitted information is true. accurate, and complete. I am aware that there are significant penalties for submitting false information,

including the possibility of fine and imprisonment.

~---'- ------ NAME (print or type) : SIGNATURE -~TE SIGNED--

I I i i

X. OPERATOR CERTIFICATION

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and al/ attached

documents. and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the

submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, .. .;'\

including the possibility of fine and imprisonment.

NAME (prlnf or type) SIGNATURE DATE SIGNED

ECL3E ·27'· ECY030-3tForm3 PAGE 4 OF 5 CONTINUE ON PAGE 5
Continued Irom paga 4.

v. FACILITY DRAWING (see page 4)

." <,

I~·.~::~~-~ '-...-.

ECL3F ·17'· ECY ~31 Form 3 PAGE 5 OF 5
.1

.1

,·1

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.~··~1

..:

ECY 030-31 INSTA.

REV. 8/82

PART A

DANGEROUS WASTE PERMIT FORMS

(FORMS 1 and 3)
Pwmlt Application Proce..

WASHINGTON STATE

DANGEROUS WASTE PERMIT

GENERAL INFORMATION

Conlldantlal Information (continued)

There are two parts to a Dangerous Wsste Permit Application-Part A and Part

B. Part A conaiata of Form 1 and Form 3. Pert B requires detailed

elte-epeclflc Information such as geologic, hydrologic, snd engineering data.

WAC 173-303-800 specilies the information that will be required from

dangeroua waate management facilities in Part B.

Operation During 'ntarim Status

Part A of the permit application defines the proceeaes to be uaed for treatment,

storage, and dlspoaal 01 dangerous waates; the design capacity of such pro'

c....a; and the apeclflc dangeroua wastes to be handled at a facility during

the Interim atatua period. Once Part A ia aubmltted to the Department of

Ecology, changea In the dangeroua waatea handled, changea in design

capacities, changea in proceasea, and changea in ownership or operational

control at a facility during the interim status period may only be made in eccordanc. with the procedures In WAC 173-303'820. Changea in quantity of waste

handled at s facility during inlarlm status can be made without submitting a

revlaed Part A provided the quantity doe a not exceed the design capacitiea of

th. proc.aa.es specified in Part A of the permit eppllcation. Failure to furnish all

Information required to process a permit application ia grounds for termination

of an Interim ststus permit.

ConfldenUal InformaUon

Alf Information submitted in thia form will be subject to public disclosure, to the

.xtent provld.d by RCRA and the Freedom of Information Act, 5 U.S.C. Section

552, and EPA's Buslnesa Confidentiality Regulations, 40 CFR Pert 2 (afle

• ."ea.11y 40 CFR 2.3()6), 'and will be aubject to tha Stetfl of Washington Public

Recorda Act chapter 42.17 RCW and chapter 43.2IA-180 RCW. Persona filing

thle fonn may make claima of confidentiality. Such claima must be clearly in·

dlcatad by marking "confidential" on the specific Infonnation on the form for

which confidential trealment Is requested or on any attachmenta, and muat be

Iccompanled, at the lime of filing, by a written aubatentlation of the claim, by

anlwering the following questions:

Eey 030-31 INSTR.

Eel! -273-

A. Which portions of the intorrnation do you claim sre entitled to confidential

treatment?

B. For how long is confidentisl treatment desired for this information?

C. Whet meaeures have you taken to guerd sgainat undeaired dlaclolure of

the information to others?

D. To what extent hes the informetion been diacloaed to othera, and what

precautiona have been taken in connection with that dlacloaure?

E. Has the Department of Ecology, EPA or any other Federal or State agency

made a pertinent conlidentiality determination? If ao, what would those harmful

effects be and why should they be viewed as substantial? Explain the causal

relationship between disclosure and the harmful ellecta.

If no claim of confidentislity or no substantiation accompaniea the Information

when it is submitted, EPA or the department mey mske the Informetlon availsble

to the public without further notice to the aubmitter.

Oellnltlons

Terms used in these instructions and in this form are defined In th. Deflnltlona

section of the Dangerous Waate Reguletlon, chapter 173-303 WAC.

').r:;
~--- - -_. ------

-~"

FORM 1--INSTRUCTIONS . . .. --0' • . . . __. .. . ... _. _ ..__ ._ ·_·_.__...·0. _

Thl. form must be ;Jmpleted by all ,ppl":ants.

Completing This Form

Plesse type or prlnl. i~ ""1.:. ;or:,.. ::iIO _ 3 eacn Cl1diaCltJf t;.i1: N6er. !n~ '~iI ' ..' ;

Abbreviate if necessary '0 3tay ....1·r ,r 'ne .1wnOG' ot ·';.'"':d:",:i";le(3 alh:.·wo~

each item. Use one g:A~a '.)f Y;;.a ... --:;~'''Jeer "':)fC9 ,:,;:,;! flO' '":)1 OUr-C 1.H" ) ....

marks 14"'888 tnef a',~ ·)6e,~~·~ <: '::rl ' .. ,~u" :·usccr.se

Section I

Section VII-C

~n:t:. tr.~ acp(ocf·a·~

jd·~:iit·.I. II1.:1icate '::.j~

~J 9 '="". town, ',>-'''''1"'.

Sections VII-D - H

secuon '1111

~-:-=.- ":: fHjlr.~(9 •...13 aidsl statue of the operator of the

•. ., '1(""l~'Y 'H: =::" .)wr.~d by local government(s) such

-'I' .\q,j ~(~:ir~9.! • "'t?' JOeratof identified in Item VII-A.

,"Ui q.<islinO and proposed intako

Space is provid6d 81 fhe .Hj';'~' 'igrl' ''l "oj corner of F·Jr(''I'''•. :.:,r t~i$~;4''')r :.: .... y.

EPA/St8tejd8J'\tlfiCJ(j(/~ '~,,-:~~: ... ~; .~.,~ 3,-: 3.'\·<J.~,P.g "S::C"i. ~.r·=l· ,':J( -::,:>,

tlficaUon number. It JC1J ;.:', ·:d ...··:·: ::"'::., S;dlE' O~r:jlj i:a: J ~li;";"':"3~ .)'''Je:,~-:

contact the Departmenf )f ;..::c-~,. :~'~~' .i59,o:y).; 3f'0 ,)."I€, NlI~ ce ;;f';",,,Cfor'!

you. It your faCility 18 ne'"" (."lC'1 '/~t :.:;Hi~" .crec). 108;'0 :n18 'tem '::lId",,"

Sectlon II

Enter the facility's officia: Of ''3Qol name. :'::0 OO( us,=, a conoqutat name.

Section III

Give the name, tille, and WOII< lel"pt>ooe number 01 a pelson wno IS thoroughl.,

femlller with the operation ')1 the facility and with lhe racrs reponed in thiS acplication and who can be ccotacted if necessary.

Section IV

Give the compiete mailing .a<!dH!9S 'Jf ,' .•J .JHh..e where --:orresponden-:p. 'H~~""·, ..

be sent, This of1An 18 '10~ It'lO ;H"!d(l3~S :,ad to deslIJoate the 'ocarrcc ,1 ';'.;

facility or activity

Section V

Give the address or location of ttl" facililY Identified In Section III Of th.s form. If

the fecility lacks a street. nama or rout a number, give the most accorate al\er·

native geographic information (e· g., Secl;on nllmber or Quarter section numo,,'

from county records or st ;Iltersec1ion (";, Rts. 425 and '22).

Section VI

List, In descending orelar ,_,I .ignifican,;p'. the lour 4-diglt 8tanda..d ,na"'''a

olssslfication (SIC) Coeleg which oest -:~.;cribe your facility in IA"IlS -,1 tha :-, -

clpal product a or Si'lr....'cas you P'C'GI.C'l or provide. Also, sp,clly 4,,;-·

cla8sification in words. :-~es~ clafl3Irl";d'lt~f"lS may differ Irr;m ol~e Sll: '::.>~':;'

describing the operatic!' ·1~"'~r.~lif\g the ~,=,·"'q1lr0US WB::lteg

secuon 1)(

J~:~'/iC€o 3 IOC0'lir l~·' . -..... T'dC,<;:.t "'-; .;;'gd 9x.tending at least to one mile

":)~yond !t')~ prf)f:'B(~ c-: ,',·1j'e1 -;-' 1l'H~ !o?: Ii:', Nr.ich clearly show the following:

n~'3 oc etion an.j :,' ",·'Qr •• :.a~:.''''

ano diSCharge 31n.c:·. f e <J

o\JI hazardous Nas:~ ...·:3r.a;;emenl facdltlu~.

Each well where ·fO'.J ,~"~G: !luids underg{vund; and

All sp"ngs and su':aoa ....ater bodies in :he Mea, plus all drinking water wells

within '. mile 01 tha '. :,'ily which are iaentified In Ihe public record or otherwise known to IOU.

'f an intska or disct-"~e J!·uclu'a. haZ9'~L'''S wasla dispcsal stte. or Injection

'Ncll associated W!tt' '''i~ '9.c'lity is !ocatC-:1 more than one mile from the plant,

nelude ;1 00 thA mao ' .. ,"",ble. I! not. al!ach additionsl aheets describing tha

'"cation 0' the 51 ...sc: .-, !'8C )sa' sue. 01' ,_e'l. and identify the U.S. Geological

S~lrve'y' (or ,)Thor) 'n~:) ' .. ··'3S00(lrj~ng to :I'd .oceuon

Or. asch map. .ncu..:;:' '~;. "T':ep scaie, d Tiendian arrow showing north, and

latItude and lor.C;;l!~JI':':' ~' ~·3 ('le8~e8t whOle saccnd. On all. maps of rivers. show

ir.e ,Jiraction of :hs c..' -r" M,;j in lidal Nalers, snow the d"ections 01 the ebb

and !Iow ,ides, U98 3 ". , :"muta sense map published by the U.S_ Geological

Survey, which may:>" .Ola,ned through Ihe U.S. Geologicel SUNay Offices

listed below. If a 7 - '? ~"r",U ,elies map 'las not been publlahed for your faclli·

1'1 site, Ihen you ms, J~" a 15 minute ,eries map from the U.S. Geological

Survey. If neither a ,. '. '0' • 5 minuta s,,';ag map has been published lor your

facility site, use a ala'. "ep or other aporopriate map, including all the re·

qUG8led information' ,. ",s :aae, brief!y ,1escribe land uses in the msp ares

(e II ' residential, co"",,~,c.ell. .

You may I.race your .,dO Irom a geologicsl aurvey chart, or other map meeting

the aoo·,e specificR! ,;n; ,cu do, your .;-'Ap .t1Ould ba~r a note showing the

numoer or tille 01 :"<: .~~ ~r ~hart It wa' :raced from. Include the names 01

;-:ea:br :C·N03. waldo . .jr'{J or;)rnmer,' . ':'((3

SIC code nUmCgfS IHe "j'='8C:·I':tIG~.3 hr.:..... '1'ay De 'Ot.;nd in the '.~13t·dn··-:

duerrlsl Classification ~3nuJ]I" Or~;."lBrt")'1 :;., th'3 E.<eCl,;!IV9 OffIC~ ":' '-;9 ~.-:!

dent, Office of MfH"llt'.J#)m4jnl~IO '3l;d']p~ Nnich :S 3'1a:iet.ie 'ret!": :~e ,3c .... ~:'

ment Printing Ortice V'/~.9~lr~:;;1)"'I ') C, '_ ".;~ ·h~ .::urref)f fiqJ1..:n ::d 'r-,:, ~laf~' ...l

you have any questiol1S ,,:()r:.:e:(PI:1,'; ltp "Joroppa~e SIC ":'CC9 '0'- /')~Jr fa.:.'

contact your Depanma'1~ :,i =-:'1iCrj!' '~I?-;:~ 'ill ..)tHce ('~oe T3:b'e \~.

Northwesl RMIO~.' ': " ';e

4350 - 150th NE

Redmond, Wa'",,"yl~r :;',.,:~

Tel: 206-885- 19{)'C

Eastern ReOlonal C(!tC~

Esst t03 Indiana

Spokane, Ws::!.r.mtdl;.."'" ';d-,C."

Tel: 509-456-2'l2C'

Section VII-A

.;',y;!:;vo.d:', ;:;'.:Qr.,'d. :'l~\{')

~2·': ;~It:U~Na'~( _~~·D

:. ·"·"~:HiL ,\t a 5;- !l'~' .>~ .;.=;.:. j.

r_ l ." :'; - "c,: ! -· .!: f. l

C'antr9.: (leQ,nr'8: ~:!t,<:e

360 \ Ivl)$f ·Nii~!"", ... ;r ':-('1

'8k.Irr.O, v"4'£I1n"1':;:vf' jt!HC:)

~.t 5("':.~ - 5" :' - '- ;

U.SG,S '_'F:

Nt3stdrll Mac..c,,'I •.;

...a!I.~:'aj Cd;'·;";'

:':.3~;er

1.15 \'iddlefi~I'~ :;. -:

V~·l.,: ,J9Ik,. :-:'a ).

::'-~I""" \ll1 !t· '1,

3r·'3th,· ·je~crlbe tM'? . ~'

:;. ..·,nee

AREA SERVED

ArIZ., Calit., Hawaii, Idaho,

"0'.. Oreg., Wash., American

Samoa, Guam, and trust

1el':!tori~8

< ' ~p)(lUC: s produced or services

Give the name, as :t IS 'Ogddy :atauiJlJ ':; ::1 the petscn, j;rm, puo:.c organl.zo

tlon, or any other entity 'rIPICh::eenHes , ... facility cesc!!bed ;r. ;:!"l:<j apc.!ka:lC-.i

This mayor may n(it be ~~,e fJarr.€ non"'e as the facility The OP(:I atcr -,f the

facility is the legal er.ri1y A'liC:", C..;,,~{~~S "~e ~e'::I:I~Y'S opara:I:'t'J -;:Hl,fir thitl1 "'.-.

plant or site mana';;d; Or I. d"=:·l:::. ": J.d - ,.H::~,

Section VII-B

Indicate whether Iha ant it'I which opara:es Ihe facility alao owns it by marking

the appropriate box.

ECY 0»31 INSTR.

ECL2 -273-

SecUen XI

F:or d corporation. Ci :1 .)c".; :Ipal executlv., officer of at least the level of vice

Of'3Sldent

F::r :Jar!,1erghipi( lCl~ ;:.:.:.:' ;)·~rg!"llp. : •.j -;~:l-:lt":\l pd!1ner or the proprietor,

reepect.vely: or

For e municipslity. State Federsl, or other public fscility, by alther s prIncIpal

executive o!ficer or ranktng 'elected o!ficlal.
FORM

1

State of

Washington

Department

oHcology

••ASHINGTON STATE

DANGEROUS WASTE PERMIT GENERAL INFORMATION

(Read "Form I instructions: before atarting)

!PA/STATE 1.0. NUMBER

II. NAME OF FACILITY

H I I I I I I I I

III. FACILITY CONTACT

A. NAME & TITLE (last. first, & title) B. PHONE (araa code & no.) HI I I I I I I I I I I I I I I I I I I I

. IV. FACILITY MAILING ADDRESS

A. STREET OR P.O. BOX j

" "

H I I I I I I I ! , I I I , I I

, I

B. CITY OR TOWN C.STATE D.ZIPCODE

~'l I I I I I I I I I I , I , I I , I I I I I I I

V. FACILITY LOCATION

A. STREET, ROUTE NO. OR OTHER SPECIFIC IDENTIFIER

I I I I I I I I ,

B. COUNTY NAME

I , I I I I I I

C. CITY OR TOWN D.STATE E. ZIP CODE F. CO}/mJ.£OOE

H' , I I I I I I I I I I I I I I I I I I I I I ;.

.;.

.".,:

IV. SIC CODES (4-digit. in order of priority)

A. FIRST B. SECOND , I (_clfy] 1 I (speCify)

C. THIRD D. FOURTH

1'1 I (specify] H I (speci/y]

I

VII. OPERATOR INFORMATION

A, NAME B. la the name Uated in

- I I I I I I I I I I I I I Item YU-A also the

owner?

DYES DNO

C. STATUS OF OPERATOR (Enter the appropriate letter into the answer box; if "Other", soecitv.) D. PHONE (ar8a code & no.)

F -FEDERAl M m PUBLIC (other than federal or state) ! I (specify) I I II I I II S - STATE o OTHER(apecify) I

P - PRIVATE r---------i

E. STREET OR P.O. BOX

I I I I I I I I I I I I , I I I I

F. CITY OR TOWN G.STATE H. ZIP CODE VIII. INDIAN LAND

-- I I I I I I I I I I I

I

I

I I I I I

Is the facility located on Indian Ianda?

DYES DNO

-

COMPLETE BACK PAGE

ECY0»31

eQ.4 -279-
~~----_._- ------_. .----------------_._----- -- -----

IX. MAP t------.---------------.------------------------------------

Attach to this application a topographic 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 and proposed intake and discharge structures. each of its hazardous waste treatment,

storage, or disposal facilities, and each well where it injects fluids undergound. Include all springs, rivers and other surface water bodies in the

map ares. See instructions for precise requirements.

X. NATURE OF BUSINESS (provide a brief description)

XI. CERTIFICATIO~ (see instruct~e...'!.-,-s,--)----------------------;---------------------------i

: B. SIONA;.·U·-AE------·-----------·----------.,-C.-O-A-T-E-S;-O-NE-O--------'

I certify under penalty of iaw that I have personally examined and am familiar with the information submitted in this application and all attecnmems and that. bas~d on :ny inquiry of those persons immeaietetv responsible for obtaining ;he information contained in the application, I

believe that the intormetion IS true. eccurste and complete. / am aware that there are significant penalties for submitting false information, including the possibitity of tuie and imprisonment.

A. NAME & OFFICIAL TITLE(type 0' pron,)

ECY0»31 Reve,...
Completing ThIs Form

FORM 3 -INSTRUCTIONS

Section III

Please type or print If "(JU pnnt place each cnar acter :::etw8'!." ,~'!

marks. Abbrev.are ,f "er::"ssa'y :0 st.iv within tne .,,,I1',:',,r ;: ,:r'd',,:';,

allowed for eacn 11e~n. I)S~ ,Jr'le 3P8·:e for'jr~af(s Je:w~A.-· ~·:t:-:

not for punctuation marx s unie ss they are ~p.eaea to c.antv r: .... response. .

8ecUonl

Exi6iing dangerous wast» manirgenent raciut.e s ,"0,,"1 '!"'".' "'_' I

EPA/STATE Identilicatior NI'''1~er ('I known). N.,,,,, 'a'>;,\,e,,; '.~C'.

leave this item !:llank

Section"

A. FIRST APPLICATiON, ii thiS '3 the (jrSI llppl'C81!Gi1 ',hat is :->2'~''; '."",

for the facility ptace an" X" in srrner the Existing Fd':I!i!1 nox ::: ,pe "£'"

Facility box,

1. EXISTING FACILITY. EXisting facilities are.

a. Those facilities which received hazardous waste for tr ea rment, storage. and ior disposal on or befJre November 9

1980; or

b. Those facilities tor wrucn construction had commenced t.cor before November 15.. 980, Construction had" commence (:

only if:

(1) The owner or )Derstor had obtaine1 aU ,1GCeS"" .

Federal. State. a~::l .o za: oreconstrucuor, appr overs ); c'?

mils; and

(z-a) A, continuous onvs.car. on-jite cor.:;:-'J·:':.:'

program had begun (facility design or other prelfmmar)i

non-physical .~nd n(ln-site specific pre.o8rarr:;rv

activities do not constitute an on -ssue construcu-z-:

program). or

(2·b) The owner or operator had entered into contr actuaobligations (options to purchase or contra CIS for tees.cu.r.

engineertng. afld design studies do il0t coast.ti.s e ;.;.

trectuet obligations) which could not be canc euec ;r

modified without sub stantial ross. Gerieratlv. 3 c-ss,

deemed substannet 'f the amount an owner or OC,"'~:,:'

must pay :0 CatIC€': :..:-r:s;rvctlcn agre2:Tlents 0; 5~ .:.::

struction exceeds 'f>~: of the total oroiect cost

EXISTING FACIL:r', c:.\,:,::.;r the E.<isl,n\l Fde,Lt! Cu., .;-

en. enter the dare ,janG'?~0';S waste operations DP.gli~ (;.'~ 'h"

date the facility beqe» 'reating. Slo(ln.;;. or disoos.o-;

hazardous waste; :,' 'i"''':- J:~ :-.nstf~,n::t:Gf' : )r-::T;E:f,:e,;

2. NEW r"c:ur~ 'd·... ·(j: -: e s are a '3·: .:..e~ ";r t;C·

struction COiT''''·€··:'2(~. :. ," f :;r"me·'"l·':2. :':f'~( ~~!)"S-""':'''2'

t980.

NEW FAClliTv S4.7::: ":he N~w F>.cd't'f :;'< S 'l'\a''''''~ ,~."

the date tha: .:ccr:;:. :'r. :~~dalj .:" :3 eX:J(~':!~~-: ~.:- :)~9'~

8. REVISED APPLICA : 1<:)"i ,I :r-,5 :s a SlJOsllqc6'" ,J;'c.,ca:·v,' .~~.

being filed to amend -;a:3 tll~d r d pr''''''CIJS aO~'lc j~':r. :,).::iC~ :,~

the appropriate bOl( Ie m~lca·e "H"etl~-er one far:I:\~\/ ""':~'3 ~~~ .. --

a permit.

1. FACILITY HAS AN ,N:ERIM. ST TUS PER~'iT "':a<:e a" '.( '1

this bo/( if this is a revlS'.ld dpplicat!on to mak'j cf:anges a: il ·~.G .. '-

ty during the interim '3~atus oeriod.

2. FACILITY HAS A ~INJI.L :OERMIT, Place an 'X In or-IS !).: '.. 1 :"15

is a revised appl:catlon 10 .nake cnanYes at a :ac:ii!~ !or ",r·.';I' .;

permit has been issued.

(NOTE; When submitting a revised application. applicants must

resubmit in their ·entirety each ifem on the application for which

changes are requesfed. In addition, /lems I and IX (and Item X if ap·

pllcab/e} must be completed. /I is n"t necessary to resubmit information for other items that will not change).

ECV 030-311NSTR. Form 3

rne mtorrnat.on '" :>ection l:1 cescr-bss all the processes that will be

;se'J :0 tr ea: s:~r7. or c.sccse ':)f jangewus wsste at the facility. The

(Jr)s'·;r, ;:a03:::::/ .:i ea:':1 orcce ss must be provided as part of the

.ies cr.ct.oo. ~r,e des.cn capacity ot ,nJection wells and landfills at ex-

,sting facilities shOUld be measured as the remaining. unused capact-

:'r' See the loon 'or tne cetailec .nstrccuons to Section III.

5eclloniV

The ,mOr"al':" .n Sec non IV cescnoe s all the dangerous wastes that

..... 11i ':-1 trealS'; stereo. cr crscceeo at ihe facility. In addition, the processes that ,,"iI 'Je us ec to treat. store. or dispose of each waste and

'1>e e surna t ec F'l~a, ":;',3":';'{ vi ')a:~' .. asre must be provided. See

'l"d ° ';rrt '~r :'r'~ ·1eta:le.: i!S~(uct!crs.·oSection IV.

Sectien V

,l.1l eXISl1l19 -ac.nuas must include a drawing showing the general

layout at ihe lacility. This drawing snouto be approximately to scale

and fit in the soace provided on the form. This drawing should show

the follOWing

The property boundaries of the !acility:

The dlees cccupied by all storage. treatment, or disposal operauons ina: .. ·11 De used during Interim status;

7'r.,: :e.,-., J' each operation. (Example-multiple hearth incmers: :« Jr'.111 storage area, etc.);

Areas 0:1 c sst storage. treatment, or disposal operations;

Ar aa s oi ;ulure storage. treatment. or disposal operations; and

The approximate dimensions of the property boundaries and all

storage. 'ieetment, and disposal areas.

Section VI

All existing facilities must include photographs that clearly delineate

all ex,s!,r..;; structure s: all e/(isting areas lor storing, treating, or

dispos'~g .:;f naz ardous waste; and all known sites of future storage,

:re9',I1',',,, ;f : se0581 operations. P~\-Jloglaphs may be color or black

ard ·Hnole. gr :urcl-Ievel or aerial. Indicate the dale the photograph

..as take" :n '~e back of each phclOglapr..

Section V11

::r.:;;.. :[\~ 2-" :2 one: ·.)ngltJO'.l of th., 'acllity In degrees. minutes, snd

3eC~,;,:Js ;; ,r :' ":;er 'a:.Iit:o;1S. en'ef :he latitude and longitude at the

~;:P':A'11a'" ",';-oc'rt )! the (,edit·!, '(J~ may use the map you protide\) ;~r 30:c' v" ,X :.1 i',)trn : :0 '~etermine latitude and longitude.

'_at':~O'3 dr,~ ',crgltt:de IniormallC~ 's 31so available from Regional Of-

'Ices )1 '''e '; '" Oeoartmel1t of IPl"lrior Geological Survey and from

~'.1!" 1 ;.;nr. ';0 iUC' as rne Oepar:me,)t of Natural Resources.

Section VIII

Section IX and Section X

L\1l iac:iity owners must ~'.;n Section IX. If the facility will be operated

t:! someone other than ... c' owner. then the operator must sign Section

',( Federal regulations require the certificatior. to be signed as follows:

A. For a corporation, by a principal executive officer at least the

level of vice president:

B. For a partnership or sole proprietorship, by a general partner

or the proprietor, respectively; or

C. For a municipality, Stste, Federal. or other public facility. by

either a principal executive officer or ranking elected official.
..._,.., , It. ""0".1010;11101 a. vao VIII'

!CY 030-31 Form 3 PAGE 1 OF 6

_. ._. _ ........ .u......- ••_ ... ...-

Cl3B .~

(m/-in .r...• ,. apeced lex ./JI. type , i.«. .. 12ch.r.ct.ra I inch) -. .

FORM I. EPA/STATE J.D. NUMBER

3 . DANGEROUS WASTE PERMIT APPLICATION r -\ I I I

FOR OFFICIAL USE ONLY

APPUCA.!!.'?N D/~~E ~:~EIV;'D COMMENTS

W I I I I I

II. FIRST OR REVISED APPLICATION ;

P18ce an "X" In the appropriate box In A or B below (mark one box only) to indicate whether thia ia the firat application you are submitting for your facility or a revlaed application. "this

I. your flrat application and you already know your facility's EPA/STATE 1.0. Numbar, or if thia Ie a reviaed application, enter your faclllty'a EPA/STATE 1.0. Number In Section I.bove.

A. ~ST APPLiCAnON (place an ..x..below and provide the appropriate dBfe)

0 1. EXISTING FACILITY (S••ln.,ructlon.'or d.finlt/on ol ....ialing .. tscuttv. Q2. NEWFACILITY (Comp/el.llembel_.)

Compl.t. it.m b.lo...)

FORNEWFAClUT1ES.

PROVIDE ntE DATE

~~~ FOREXISTING FACILITIES, PROVIDE THE DATE (mo.. d.y. & yr.)

--T-i~~ (mo., day. & yrJOPERA.

OPERATION BEGAN ORTHE DATE CONSTRUCTION COMMENCED TlONBEGAN ORIS

(ua. the bo••a to Ih.,.ft) ---l..-...j EXPECTED TOBEGIN

8. REVISED APPLICAnON (plBce sn ..x..below Bnd complete Section I above)

o 1. FACILITY HAS AN INTERIM STATUS PERMIT o 2. FACILITY HASAFINALPERMIT

III. PROCESSES - CODES AND DESIGN CAPACITIES

A. CODE - Enterthe code from the list of process codea below that beat describes each proceas to be used at the facl/ity. Ten lines are provided for entering codes. "more

Ilnea .,. needed, enter the code(a) In the space provided. If a process will be used that is not included In the I/st of codes below, then deacrlbe the proce.s (1ncIvdittQ1t8 deaIgll

~cIty)In the apsce prOVided on the (section /II·C).

.. PROCEll D!SlGN CAPACITY - For sach code entered in column A entar the capacity of the process.

1. AMOUNT - Enter the amount.

2. UNIT OF MEASURE - For each amount antered in column B( 1>, enter ths code from the lIat of unit measure codes balow that dascribeathe unit of measure used. Only the until 01

meaaura that are IIstad below should be used.

PRO- APPROPRIATTEUNITSOF PRO- APPROPRIATTl! UIIIT8OF

CESS MEASURE FORPROCESS CESS IIl!ASURI! FORPROCI!88

PROCESS CODE DESIGN CAPACITY PROCESS CODE DESIGNCAPACITY

i Storage: Treatm.nt:

CONTAINER (barral, drum, etc.) SOl GALLONS OR LITERS TANK TOI GALLONS PER DAY OR.

TANI< 502 GALLONS OR LITERS LITERS PER DAY

WASTE PILE 503 CUBIC YARDS OR SURFACE IMPOUNDMENT T02 GALLONS PER DAY OR

CUBIC METERS LITERS PER DAY

SURFACE IMPOUNDMENT S04 GALLONS OR LITERS INCINERATOR T03 TONS PER HOUR OR

METRIC TONS PER HOUR;

DIapoNI: GALLONS PER HOUR OR

INJECTlON WEU 079 GALLONS OR LITERS LITERS PER HOUR

LANDFIU. 080 ACR1.·FEET (the volum. thaI OTHER (Use for physical, chemical, waul cover one ecre to B thennal or biological treatment T04 GALLONS PER DAY OR

depth 01 on. 1001) LITERS PER DAY OR HECTARE·METER proceases not occurring in tanks,

l.ANOAPPUCAnON 081 ACRES OR HECTARES surlace impoundmenta or inciner·

OCEAN DISPOSAL . 082 GALLONS PER DAY OR atora. Oeacrlbe the proceaaes in

LITERS PER DAY the space provided; Section III·C.)

SURFACE IMPOUNDMENT 083 GALLONS OR LITERS

UNITOF UNITOF UlGTOF

MEASURE MEASURE , MEASURE

UNIT OF IlllU8URE CODE UNITOFMEASURE CODE UNITOF MEASURE CODe

OAU.ONS ................... ....... ..... . G LITERS PERDAY... . . . .. . ..... .... ........ .. ... V ACRE·FEET . .......... A UTER8 ............... L TONS PER HOUR .... . .... . . . . . . . . . . ........ ..... 0 . ...... .. , . . . .. . ........... ...... ....... . ........ HECTARE·METER .. . ..................... F CUlllC YARDS ........... Y METRIC TONS PERHOUR ., ...... ........ W . ...... ... ... ,. ....... ACRES . ..................... B CUlllCMETERS ............. C GALLONS PER HOUR . ...... E ........... ....... .......... ..... ... .. , ...... .... ...... ... HECTARES .......... ........................ Q GAU.ONS PERDAY ...... ... .... ........ ..... .U LITERS PER HOUR ., .. , .... ....... .. ......... H .....

EXAMPLE FOR COMPLETING SECTION III (shown in line numbers X-I and X-2 below): A facility has two storage tanks, one tank can

hofd 200 gallons and the other can hold 400 gallons. The facility also has an incinerator- that can burn up to 20 gallons per hour.

N

B. PROCESS DESIGN CAPACITY ! N B. PROCESS DESIGN CAPACITY

U A.PAo- 2. UNIT FOR U A. PRO- FOR

cess OFFICIAL CESS 2.UNfT LII COD£ OF MEA· LM CODE OF lin· 0fllI1CIAL

t It 1. AMOUNT SURE USE I B 1. AMOUNT SURE USE

"E (lromliat (ep.city) (enter ONLY NE (trom Ii.' (opeclty) (/HIler ONLY

!R abo ..) code) ER abov.) code)

! i.-.J t--

r·/ S 0 2 600 GI 5

r-2 T 0 J 20 E 6 --

f 7

2 8

J 9

4 I-- 10 -.~ - .• ................_-. -_.. _..-.... ~_. _•• ..-.~ ...... .• w·· • ..-. ... ...... ~_.~.

-
Continued from the Iront

III. PROCESSES (continued)

~~~~----------~-~-~---.

~------------------------------------.>---~"--

C. SPACE FOR ADDITIONAL PROCESS CODES OR FOR DESCRIBING OTHER PROCESS (code ·'T04··). FOR EACH PROCESS ENTERED HERE INCLUDE DESIGN CAPACITY.

IV. DESCRIPTION OF DANGEROUS WASTES

A. DANGEROUS WASTE NUMBER - Enter the four digit number from Chapter 173·303 WAC for each listed dangerous waste you will handle. If you handle

dangerous wastes which are not listed in Chapter 173-303 WAC, enter the four digit number(s) that describes the characteristics and/or the toxic contaminants of those dangerous wastes.

B. ESTIMATED ANNUAL QUANTITY - For each listed waste entered in column A estimate the quantity of that waste that will be handled on an annual basis.

For each characteristic or toxic contaminant entered in column A estimate the totat annual quantity of all the non-listed waste(s) that will be handled which

possess that characteristic or contaminant.

C. UNIT OF MEASURE - For each quantity entered in column B enter the unit of measure code. Units of measure which must be used and the appropriate codes are: •

ENGLISH UNIT OF MEASURE CODE METRIC UNIT OF MEASURE CODE

POUNDS... . . .. . .. .. .. .. . . . . .. .. .. .. P KILOGRAMS.. .. .. , .. .. K

TONS. .. T METRIC TONS. .. .. .. .. .. .. M

II lactllty racords use any other unit of measure for quantity, the units of measure must be converted into one of the required units 01 measure laking into eccount the appropriate denaltyor apeciflc grevity of the waste.

D. PROCESSES

1. PROCESS CODES:

For lIated dangeroua waste: For each listed dsngerous wasle entered in column A select the ccdeta) from the list of process codes contained in Section III to btdloate how the

waste will be stored, treeted, snd lor disposed 01 at the facility.

For non-Uated dangerous wastes: For each characteristic or toxic conteminant entered in Column A, select the codets) from the list of process codes contained In Section 11\

to indicate aU the processes that will be used to store, treat, and. or dispose of all (he non-listed dangerous waaies that possess that characteristic or toxic contaminant.

Note: Four spaces are provided for entering process codes. If more are needed: (I) Enter the first three as described above: (2) Enter "000" in I. ••."IJme right box olltem

IV-D( 1); and (3) Enter in the apace provided on pege 4, the line number and the additional code(s).

2. PROCESS DESCRIPTION: If a cooe is not listed for a process that will be used, describe the process in the space provided on the form.

NOTE: DANGEROUS WASTES DESCRIBED BY MORE THAN ONE DANGEROUS WASTE NUMBER - Dangeraus wastes that can be described by more than one Waste

Number shall be described on the form as lollows:-

I. Select one of the Dangeroua Waste Numbers and enter It 10 column A. On We same line complete coturnns B. C. and 0 by estimeting the totel annual quantity of the

wa8te and descnbing all the proceases to be used to ir..st. srore. ano . ar aispose ot the waste.

2. In column A of the next line entar the other Dangerous 'Naste Number that can be used to describe the Nu:e -n coiumn 0(2) on that line enter "Included with above"

and make no other entries on that line.

3. Repeat step 2 tor each other Dangerous Waste Number that can be used to oescribe the dangerous waste.

EXAMPL£ FOR COMPLETING SECTION IV (shown in line numbers X· I. X-2. X·3, and X·4 below) - A facility will treat and disoose of an eatimeted 900 pounds per year 01 chrome shavInga !Tom leather tanning ano finiahing operation. In addition, the facllity.,ill treat and dispose of three non-listed waslas. Two wsstes are corrosive only and there will be an "tlmated

200 pounds per year of each wasre. The otr.er waste IS corrosive and ignitable and there Will be an estimated 100 couno s per year of that waste. Treatment will be in an Incbterator and

disposal will be in a landlill.

i - L A. IC.UNIT D.PROCESSES

IN DANGEROUS! B. ESTIMATED ANNUAL OF MEAWASTENO.! SURE

NO QUANTITY OF WASTE (enter 1. PROCESS CODES 2. PROCESS DESCRIPnON

E • (_ercode) , COde) (enter) (if B coae a not entered in DCrJ)

I , I I ,

X-I K 0 5 14; 900 P, T 0 J D 8 01 I i : . I I I

jp: , I ! I I I ! I

X-2 D 0 0 2 400 rr 0 J D 8 0

I I I I I I I I

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

I , I I I I I I

included with above X-4 D o 0 2 T 0 3 IV 8 0
Continued from pege 2.

NOTfil PIIolOCOf!Iy thill page before completing if you heve more msn 26 westes to list

1.0.NUMBER (enter from pllge I)

I I I ! i I I !

IV. DESCRIPTION OF DANGEROUS WASTES (continued)

L A. ! C. UNIT D. PROCESSES

I N DANGEROUS B. ESTIMATED ANNUAL ! OF MEA·! I

I SURE I !NO WAITE NO. QUANTITY OF WASTE 1. PROCESS CODES I 2. PROCESS DESCRIPTION (enter E . (...,.code) t te~ I

(ente,) I lif e code " no, enfMod in 0(1))

-----r I

I i I I I I , : I I I I

I I i i , i : j

! I

!

I

I I I I i I I i I 2 ! I I

!

I

I i I I I I , I

I I I I

3 i ; ,

! I ! I !

i I

4 : I I , I ,

I I I I I I ,

, I I

I I , 5 I I -I ,

-+ I

I I I I i

I

I I I I

I 6 , I I , I I I I ! ,

7 I

i

I I

I I I I I I

8

i I I I I I

i I I I I

I I

9 I i I

I I i , I I I I I I

10 I '-

. I , : I I I I 1

II

I I I I I I I I

12 ..

I I I I I I I I I

13 I

I I I I I I I I I

I I I

14 ; I 0' ;

I I I ; I I

i

I I I I ! ;

15 i I I I I

i

; I I ; I I I I

I i I i 16 I

I I I

I I I ;

I I I i I

I I I

17 i : ,

I ,

I I I I i I I

!

I I

i !

18 , ;

, I I

I J: I I i I 19 I !

{- HI I

I I !

I

I I I I

I !

20 ,

I . i I I I, I I : I I I

21 I I , I I

I ! I I ! I I I I I I , 22 I I

I I I

i

I I ! I , , I I

23 I

I

, , I I

I

I I I I I I .

24

I I I I I I I I

25

I I I I I I I I

26

ECL30 ·271· --~'--" - .. PAGE ~OF5-----..----..---·····-' ·_·_·__·•·•••..•·__·'-·_..CONT1NUEONREVERSEi

(enler "A", "S", "C" elc. behind Ihe "3" to identfty photocopied IMQe~ .
Continued from the front.

IV. DESCRIPTION.)F DANGEROUS WA, .•S (continued)

E. USE THIS SPACE TO LIST ADDITIONAL PROCESS CODES FROM SECTION D(1) ON PAGE 3.

V. FACILITY DRAWING

All exlatlng facilities must include in the space providad on page 5 a scale drawing of the facility (see instructions for more detsil).

VI. PHOTOGRAPHS

All existing facilities must include photographs (seriel or ground-level) that clearly delinaste all existing structures; existing storage, treatment and disposal areas; and

attea of future storsge. treatment or disposal areas (see instructions for more aeten).

VII. FACILITY GEOGRAPHIC LOCATION

LATITUDE (degrees. minutes, & seconds)

w--H-W I 1 I I

LONGITUDE (degrees, minutes, & seconds)

,111~1111

VIII.

o

FACILITY OWNER

A. If the facility owner Ie also the facility operator as listed in Section VII on Form r. "Generallnformalion", place an "X" in ths box to the Isl1 and skip to Section IX below.

B. It the facility owner is not the facility operator as listed in Section VII on Form 1, complete the following items:

1 I 1 \

I I

3. STREET OR P.0: BOX

'~--~--,-~-----~-----

J ! t

IX. OWNER CERTIFICATION

I certify under penalty of law that I have personally examined and am familiar with the Information submitted in this and a/l attached

documents. and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the

submitted information is true. accurate, and complete. I am aware that there are significant penalties for submitting false information,

Including the possibility of fine and imprisonment.

NA~E (prlnf or type)

X. OPERATOR CERTIFICATION

SIGNATURE 1 DATE SIGNED

I

I

I

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and a/l attached

documents. and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the

submitted information is true. accurate, and complete. I am aware that there are significant penalties for submitting false information,

including the possibility of fine and imprisonment.

NMtE (prlnl or type) SIGNATURE DATE SIGNED
Continued from page 4.

v... FAClLrrV DRAWING (see page 4)

..........

ECL3F ·171· ECY 0»31 Form 3 PAGE 5 OF 5
( I

)~·g-3

GENERATOR ANNUAL DANGEROUS WASTE REPORTFORM 4

(Required by WAC 173-303-220( 1) )

Return Completed Forms To:

State of Washington

Department of Ecology

HAZARDOUS WASTE SECTION

ATTENTIf)N ANNUAL REPORTS

M/SPV-ll

Olympia. WA 98504

• A generalor means any person by site whose act or process produces dangerous wasle (OW) or extremely

hazardous waste (EHW) or whose act firsl causes a dangerous waste 10 become subject to regulation.

Dangerous waste as used in Ihis form includes all OW and EHW.
,-------- ---~~-~ - - -- -

FORM 4

P

T

K

M

WEIGHl CODE Cudtt

... 11.)\1'8"15

r .:...n09 ('.000 kg)

Pounds

Short 1009 (2.000 Ibs)

Section 14A. Description ot Waste.

;:=ordangtHOUS 'N8S106 Inal are hsled under Chaptor

173·30:'\ WAC. ental Ihu lIated nsme, abbrevlaled I' nAGeSS81Y

For unhaled denge10ua waatea or mi)lture8 of

dangerous wastes tdanllfled under ChRpter 113-303.

WAC. enter Ihtt deecupuon which you belluve besl

de6Crlbes the wa ate Include the epecmc menu'actur

log or other process lJ.lnOl8tlllg the wattte and. if

known. the cttermca! Or geneflC chemrc at narne of tho

we ate

Section 14. Waste Identification

AlllnfOfmation In thllt section must be entered bv line

number Each line entry will ceecrwe the lotelan"ual

amount of each wftSlo .,hlpped 10 Ihe lacllity identitled

In Secuon to PIRes.. mtike the proper noreuon of the

phYSical at ate . ttlll1 c;htjlUlc;'al nature ul H8t:h waale

Section 148. Dllngeroua Wasle Number

For lIated we etee. enter Ihe danlJtlr,ltl. waule

uumber whldl Indenflhtts Ihfll waele

For a mixture 01 more lhan one lIaled waste. enter

ttach 01 the appucable dangerous waste number. Four

epecee are provided If mor e epece is needed, conIInU8 on the noatllne(s) eon re...... e all otner fntormeuon

on that line blank

For unlusted dengerous wastes, eow, the dangerous

wssle numbers applicable 10 Ihe waste (ret. WAC

173·303· 10~).1f more than tour spaces are requited,

follow the procedure deSCribed above.

Section 14E. Weight Code.

Enter lhe Weight Code 10f Ihe Quantity ot waste

described on this IIna Units of Weight which mUll be

uaed In thill report and tho approprtale codes 818

Section 14C. Waste Deslgnallon.

Indicate whelher the w8ste IS lJosignaled dangerous

or e,ll;tremely hazardOUS 8S delermined under WAC

173·303·070 through 173·030·10~. Enler the cor responding code

OW·-Dangarou8 Waete

EHW-EKtramely Hazardous Waste

Section 140. Amounl 01 Waste.

Enter thelolal amount or this walle (by weighI) you

ehlpped to Ihe TSO lecdity ,denillied In Secnon I' duro

'ng Ihle ,eportlng year.

Unite 01 volume MAY NOl be ueed lor reporting bUI

mus' be convef1ed Into one 01 the unils 01 weight below

laking Into account the appropriate danslty or apecitic

gravity or the waste

Section 68. County

Enter the county In whIch your waste generating In

eteueuoe is rcceteo

Seclion 7. E.Ampted Generators

It your company only \Jeneratell dangeroull waslea

that are unregulated (e g . 8Kcludftd, below quantlly

limns, etc). plea lie mdlcate ThiS Information 18

necessary becauee lhe departrnent mual dollil mine

Ihal, even thouuh you have nouued and have an 10

number. the waatea YOu generated were no' regulated

and why they were not If completmg IhlS section you

need not complete secuone 9 Ihlough 15.

Section 6. Generalor ·Conlact.

Elller the nerne nast and fir at) dnd ttjh:~pholl" nuruber

01 the person wno may bo comacrec Ittgarc1lnU mtrrr

mauon contained In thIS rapan

The owner 01 the Qttnerallng install. lion or hiS

authorized represenlatlve mUIllIlgn end date the co,

tltlc.tlon where IndIcated. The prlnled or typed name

ot the pereon signing the report must also be inctuded

where indicated.

Sec lion 8. Certlllcatlon.

Section 10. TSD Facility's EPA/STATE Identification Number

Enler Ihe EPAt Stela Identilicatlon number ollhe

TSD lacllily to whiCh you ..nllhe weate deecrlbed In

Section 14.

NOTE:

Section g. Generator's EPA/STATE Iden·

tlflcatlon Number

Enter your EPA I Slate Identification number.

A aeparate sheet must ba uaed lor each TSD Fecilily

to which you sent dangerous or extremely hazardous

waste. Plesse make extra coples of the blank term for

use In that regard. Also please enter the page number

of each sheet, 88 well as the total number of pages. tn

the lower right hand corner of each page.

Section 12. TSD Facility Addre8S

Enler the addresa 01 the lacillty corresponding to the

TSD lec,lIty'a EPA/State Idenlilication number in Sec·

lion 10.

Section 11. TSD Facility Name.

Enter the name of Ihe faclUty corresponding 10 the

TSO laclllly'a EPA/ Slate Idantilicotlon number In Sec tion 10

GENERAL INFORMATION

GENERATOR ANNUAL DANGEROUS WASTE REPORT INSTRUCTIONS -. -.------ r This repor1 must bft submitted to the Department of

Ecology. St.t. of WIshlngton. Hl!uardoua Wallie Section no laler then MsrCh 1 of the y."'u following 'he

repor1lng y.lr

Since more the" one page may be reqUired for 68Ch

repor1, enter Ihe plge number of each sheet and lhe

lolal number of pagee lIubmltled on the lower right corne, of each poge.

Section 2 thru Section 4. Generator Information

II you received a preprln'ed lebel Irom the Depart·

.....101 Ecology. all. IIto Ihe epace provided end

leeve Sectlona 2". 3. and 4 blank. II there la an errOr or

omllalon on Ih.label, cro" out thelncorreclln'orma· tlon end 1111 In the approprlatallem(el. II you did nol

receive. preprinted label. complete Section 2 through

Section 4.

section 1. YEAR

Fill In the reponing year lor thia repon.

Section 28. Generator Standard Induatrlal·

Cla••mcatlon (SIC) Code(a).

Llallhe SIC code which beal deacribea your

buaine.. activillea. Uae Ihe U.S. Dep't. of Commerce

"Slandard Indualrlal Claaailication Manual." II mora

Ihan ona SIC COdela applicable 10 your actlvltiea, li.t

all SIC code. which ba.t de.cribe your bu.ine••.

i) It you elfe only 8 generalor 0' OW: EHW. you muer

complete Form 4 only

Ii) If you .r. a gen.rator owning or operating your own

trane'.r. treatment. luorag_ or disposal (lSO) facility

and you manege ALL OW: EHW genefatod by you Or

otherB on-IUe, (I e, no OW IEHW are shipped olt·elle 10

another TSO 'acUity), you muet complete Form 5 only.

jtl) It YOu .re • Qenerator who owns or operate8 your

own TSOfaclllly end any ollhe OW / EHW you uenerale

Ormana". II aub'.Quenlly Ihlpped on.ene 10 anothor

TSO tat.:illty (whether owned f operated by your••U or

."o.he, perlon), you muat complete both Forme 4 and es.

IV) If you own Or operate a TSO lacillty only and ALL

OW tEHW are managed on-aUe, you muat complete

Form II only.

NOTE:

In'on"8110n required In eny annuel report lorm by Ihe

Depertmenl 01 Ecology may be c1aaaltled conlldentlal

by 'he reporting company. provided. Ihe compleled

form ill accompanied by a cover letter which specifies

which information is confidenllal.

If the department is requested to release Information

conlained in a con'idenllal report, the department will

notify you. Any information contained in Bny report not

claimed 10 be conlldentiel may be releesed wilhout

notice.

Section 5A. Location or Generator

If your inatallatlon location addrsss is different than

the mailing address. enter the locetlon address of your

Inalellatlon.

Section 13. Transporter(a) Used

List Ihe name end EPA ..Stile identification number

of Ihe "anaporter(8) used 10 transport wastnll 10 lhe

TSO facility named In Section 11

SQc~lon 15. Commanls.

Thl8 space may be used 10 e",platn or CISrtfy any en·

lry If used. enter a crOSB reference 10 Ihe appropriate

Secllon numbel For comment" relatBd lO Section 1~

enter the line numbel

EXAMPLE

G I EMISSION CONTROL DUST FROM

t-t--~TE~~..~£l-9E.l!q!!9t--!

WASTE IDENTIFICATION

Phy8k:81 ChemlcelI

State Nature I

14.

L M

I UII Me

E e

A

2

S-Sohd

l-ltqUld

O-SlloIetoe

O-OrgllnlC 1

1-lnOfgenlc I

A.

DESCRIPTION OF WASTE

8.

DANGEROUS

WASTE NUMBER

(see ,nalrucliona)

K 0 6 I I ..... ; I I , I , r ,.

I

I I I

, 1 , I I I

C.

Waala

Oaalgne·

lion

OWor

fHW

ow

D.

AMOUNT

OF

WASTE

Ii Idtit

E.

!i:1&I

£!o

~8

p
SI.lro/

W.shintI"'"

OelUrtmenl

of EcnlORY

GENERATOR ANNUAL DANGEROUS WASTE REPORT

Form

4

PLEASE PLACE LABEL IN THIS SPACE t. THISREPORT FOR YEAR ENDINGDEC. 31, 1

You may have received a preprinted label attached to the front of the envelope in which this pamphlet came: affix it in the designated

space above. If any of the information on the label is incorrect, draw a line through it and supply the correct information in the appropriate

section below. If the label is complete and correct, leave Sections 2.A., 3 and 4 below blank. Be sure to complete Section 2.8. If you did

not receive a preprinted label. complete ell sections.

2.A. GENERATOR EPAI STATE 1.0. NUMBER I l"r"ll-1-~ ..''-..-..--.---

NAME OF GENERATOR

I I! i I

4..GENERATOR MAILING ADDRESS

Street or P.O. Box

2.B. GENERATOR SIC CODE(S) 'r -

5.A. LOCATION OF GENERATOR (If Different from Mailing Address) 5.B. County In Which Generator

Is Located

6. GENERATOR/CONTACT

Nema (losl ftnd llrat) Phone No (ltrtt8 code &number) :! r i , -- - T r .... :- "-[T-;'r I

7. GENERATORS EXEMPTED FROM COMPLETING SECTIONS 9 THROUGH 15 (see instructions)

AS DETERMINED UNDER STATE REGULATION CHAPTER 173·303 WAC. ALL WASTES GENERATED AT THE ABOVE INSTALLATION ARE

o EXCLUDED FROM REGULATION (SPECIFY SECTION OF CHAPTER 173·303 WAC)

o BELOW OUANTITY EXCLUSION LIMITS

o OTHER (specify) ._.

8. CERTIFICAnON

--_.--_.._-_._---------.------------_._-----------------------------~

I cfulify under penslty of Isw tnet I hsve personslty exemmea snd sm familiar with the information submitted in this and al/sttsched documents. snd thst

bssed on my inquiry of those mdividusls immedistely re.sponsible for obtsining the intormetion, f believe tne: the submitted intormstion is true, sccurste.

snd complete. Ism swsre thst there sre significsnt oeoenie« for submitting tetse iotormetion, including the possibility of fine snd imprisonment.

ECl.O ~.I

PRINT OR TYPE NAME

fey 030-ze

SIGNATURE DATE SIGNED

PAGE OF
...--...-,

II. GENERATOR'S EPA'STATE IDENTIFICATION NUMBER

FORM 4 GENERATOR

'0. TSO FACILITY'S EPA/STATE IDENTIFICATION NUMBER 'r -- '1' \- [ t: ;---r , :.'

n. TSD FACILITY NAME

13. TRAHSPORTER(S) USED

'4. WASTE IDENTIFICATION

D.

AMOUNT

OF

WASTE

C.

Weat.

De.llln8-

lion

DWor

EHW

B.

DANGEROUS

WASTE NUMBER

(see instructions)

A.

DESCRIPTION OF WASTE

----------------------r--------

O:sOrOlnic S-Solid

L -Llqutd

G-Sludge

Ph,... Cllemlcel

L 8tet. Netur.

1MMe

E E

R

2

3

.- -I

4

- --j

j

I

I ,

--p~

I

t~I ,

1 - -.-

T

-,---,----+----+---+-+-----l-+-+-+-+-+-+----1

_.- r'- 1--- -,

-oro_or ---r-.'

-1'-,--..----

-- T --,--- -

r---

T , ---

T-,-

'·1 .----r-,--

.- ~r--·.-r··-- .- -r··---l--T-

--- ----.----- ------.----- -- -'r---r--, ---I -

-l

i

I

I

I

___IL _

7

5

6

11

10

12

-'5. COMMENTS (ENTER INFORMATION BY SECTION AND/OR LINE NUMBER-SEE INSTRUCTIONS)

1-------------------------- -----.-----.-.--------- -- ---------------------

ECLE -54'- acr 031>28 R.verN PAG,~E OF _
... .....

GENERATOR ANNUAL DANGEROUS WASTE REPORT

FORM 4

I

f5..:::.... - 'U '-' ..:::J lOJ ""U

'; SEP 3 1982

ecr 030-28 INSTR.

REV. 8/82
FORM 4

P

T

K

M

Code

Section XIII·B. D8ngeroul Waete Number

For listed wastes. enter Iha dangeroua waate

number which identifies the waate.

Units ct measure

P:HJn09

Short Ions (2.000 lb&)

0( liOQf.1 m3

"onnes ; 1.000 1o(g)

For a rmxtura 0' more than one listed waste.

enter eack of lhe aooncenre dangerous waate

numbers. Four spaces are provided. II more

space ;s needed. continue on the next line(a) and

reave .11 ot~er intormot,on on Ihat line blank.

[aler the amount 01 :h" waste you shipped to

ho :a':l!ity lde:'llfloo .f' secuon X during this

"C,J :,r··oq {-:tar.

Section XIII·C. Amount of Waata

Fo' unlisted da,,~erous WAstes, anter the

danqerous waste numbers Applicable to the

",·ssta. If more fhan !"ur spaces are' required.

'oucw the croc sour s :~o~c(Jbud above.

·SocHoa XIII·D. Unit ot MOllsura

Enter the unil of measure code tor the quantity

·)f waste descril1tlC on ttus line. Units ot mea8ure

w"lcn must be useo In Ihis report and the ap'

aroorrete codes ere:

Section XII. Facility .o\ddrep.n

Enler the address of the 01 the facility correnpon~ing 10 the fACility's EPA/ Stale identifica·

tion number in Section X.

~nl~f 1119 118mB of !tie !eClnty corre spondinq to

tr:e 'acuitys ':PA. Sld~e lcopi~ic.otion 'lumber In

Section X.

~ntfH lh(\ EPA' Stetl) I06miticatlOn numoer of

the ~at;jli~y to 'JrfhiCh you ~ent 'h13 wBste described

ceio.... ,n Section XIII. NOTE: a separate sheet

mUllt be used lor each facility to which you

sent dangaroue "'Asle.

Sac lion XI. f'acIUt'f Nem"

seeuon X. Faclllty's Identification Number

Section XIII. Waste Identification

All information tn this section must be entered

by line number. Each :ine entry will dascribe the

total annual amount of each 'Nasta shipped to Ihe

lacilily idenlified in Section X. Please make Ihe

proper notation ot the physical state. and

cnem-cat nature ot eech waste.

Seclion ill.. Generators ;dantlflcatlon Number

GENERATOR ANNUAL DANGEROUS WASTE REPORT INSTRUCTIONS

I i Note. - Since more than one page may be reo

quired lor aach report. enter the pags number 01

each sheet in' the lower right comer as well as

Ihe rotat numbor of pagas.

Importent: Read all inatructlona betora completing

this report. This report is to be completed by

generstors who ship lhet< ....aste off-site to

lacilities which Ihoy do nol own or operate,

Section I. Fill In tho rlsportlng year lor thla report.

Section" tnr» Secllon IV. tnetettetion 1.0.

Number. Name 01 /ns/all8/ion, and Installa/;on Mail·

ing Addreas

If you received s preprinted tabot Irom the

Department 01 Ecology, attach it in the space provlded and leava Sections II through IV blank. If

there ia an error or omission on the label. cross

out the incorrect inlormation and fill in lha appropriate item(s). If you did not receive a

preprinted label. completo Section II through Sec'

tlon IV.

Section VII. Tran.portatlon Servlcea Uaad

Llat the nsme and EPA/State identification

number of each transporter whosa aervicas you

uaed during Ihe reporting year.

section VI. In8tallatlon Contact

Enter the name (Iaat and fir at) and telephone

number of the person who may be contacted

regarding information contained in this report.

Section V. LocatIon of Inatall"Uon

If your inatallation location addreas IS diffarent

Ihan the mailing address. entar Ihe toea tion addreee ot your inatallation.

Section VIII. Certlflcetlon

The generator or his authorized repraaentstive

muat aign snd dats the certification whera indlcated. The printed or typed name ot the person

algnlng the report must also be included where in·

dlcated,

Section XIII-A. Description of Waste

For dangerous wastas tnet are listed under

WAC 173-303, enter Ihe listed name. abbreviated

if necessary. Where mixturas of listed westes

were shipped, enler the description which you

believe best describes lhe .....aste.

For unliatad hazardoua waste identified under

WAC 173·303. enter the description which you

believe bast describes the waste. Include lhe

specific manufacturing or other process

generating the waste (e.g .. Jrgen sludge from

widget fnQnufac:oti~c) and. f known. the chemical

Of generic chemical name 0t the waste.

Un;ts of volume may nOI ba used for reporting

but must be convened 1010 one 01 tha above unlta

of wSlghl laking into account the appropriate den·

sity or specific gravity of the wsate,

Section XIV. Comments

This space may be usad 10 explain or clarify

any entry. If used, enter 8 cross relerence 10 the

appropriste Section number.

Note.-Since more than one page ia required

lor each report. enter Ihe page number of each

s~ee: in the lower righl corner as well as the

tOlal number of pagen

XIII. WASTE I!>EIH1FICATION ---~--"---·--··---··-----------~-"N~~~~~·_---------

N;'~:'E.

OESC~IPTI(jN(;F WAS-'"£. -HJM6ER 0 AMOUNT ')f WA$TF

4 1 6

I

. __....__. .--l.~-.--I

·278·

K O 6 0·10( ;., ., .

lK 10'i 2";'0-63' ._-------'-,-

Example:

Slee! Fil1lsnlOg Slud.;:)e

ECLC -273- ECY 030-28 INSTR.
·- ," .. '~

SI.lte of

Wuflington

Deputment

of Ecololy

8

Form

4

GENERATOR ANNUAL DANGEROUS WASTE REPORT

PLEASE PLACE LABEL IN THIS SPACE

INSTRUCTIONS: You may have received a preprinted label attached to the front of this pamphlet; affix it in the designated space above. If any of the

Information on the label is incorrect. draw a line through it and supply the correct information in the appropriate section below. If the label is complete and

correct. leave Sections II. III. and IV below blank. If you did not receive a preprinted label. complete all sections. "Facility." means a single site where

dangerous waste is generated. treated. stored. or disposed.

II. FACILITY EPA/STATE 1.0. NUMBER

III. NAME OF FACILITY

IV. FACILITY MAILING ADDRESS

Street or P.O. Box

V. LOCATION OF FACILITY

VI. FACILITY CONTACT

1----------------------------------:------------------------1

VIII. CERTIFICATION

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents. and that

baaed on my inquiry of those individuals immediately responsible for obtaining the information. I believe that the submitted information is true. accurate,

and complete. lam aware that there are significant penalties for submitting false information. including the possibility of fine and imprisonment.

ECLD '27~

PRINT OR TYPE NAME

ECY 030-28

SIGNATURE DATE SIGNED

PAGE---.1-0F _.__
~"

FORM 4 GENERATOR ANNUAL DANGEROUS WASTE REPORT

FOR OFFICIAL 1. DATE RECEIVED I-I I 1-1 1

1

9 1I IX. GENERATOR'S IDENTIFICATION NUMBER

USE ONLY (Monlh. Day, Yeer)

(ITEMS 1 AND 2) 2. RECEIVED BY I ! I I I I I I I I I I

X. FAClUTY'S IDENTIFICATION NUMBER XII. FACIUTY ADDRESS (STREET OR P.O. BOX, CITY, STATE. ZIP CODE)

I I I I I I I II I I I

XI. FACIUTY NAME (SPECIFY) UNlTOF

MEASURE

(ENTER COOE)

XII. WASTE IDENTIFICATION

Ptly•• Chemical I ~.

L N S..t. Nature B. DANGEROUS C. AMOUNT I U A. DESCRIPTION OF WASTE Nil SaSoUd WASTE NUMBER i OF

E B L-Liquid a-Organic i WASTE E

R S-Sludge 1...lnorganic (s~e instructions) !

. I I

i I ! I 1 !

2

I

3

4

5 I : I

I

i

8

!

7 I

8

9

10

! i

11 I i

,

12 i

!

13 I I , I

! 14 i I

I I r

I I I I I

15 I , r i I I

i !

XIV. COMMENTS (ENTER INFORMATION BY LINE NUMBER-SEE INSTRUCTIONS)

I

C"" e- ""0"
TSD FACILITY ANNUAL REPORT/UNMANIFESTED WASTE REPORT

FORM 5

ECY 0»12 INSTR.

REV. 9/82
FORM 5

FORM 5 - INSTRUCTIONS FOR COMPLETING TSD FACILITY ANNUAL

DANGEROUS WASTE REPORT AND UNMANIFESTED WASTE REPORT

B. DANGEROUS C. HAND·

WASTE LING

NUMBER METHOD

(Bee instructions) (enter code)

Important: Reed all inatructlons betore completing this form.

GENERAL INFORMATION

8ectlon I_ Type of Dangeroua Waate Report

Facility Annual Report

For owners or operators ot on-aite or oN-aite

facUlties that treat, stora, or diapoaa of

dangerous waste; fill In the reporting year for

this report (e.g., t982).

Unmanffe.fed Waafe Report

For facility ownera or operatora who accept

lor treatment, atorage, or diapoaal any

dangerous waste Irom an oN-sita source

wtthout an accompanying manifast; liII in the

date the waste was received at the facility (e.g.

12-04-1982).

8ectlon H thru sectlon IV. Inatellation 1.0.

NlIIllber, Name of Instelletion, and Installation

Mailing Address

If you received a preprinted label Irom the

Department of Ecology, at1ach it in the apace

provided and leave Sections II through IV blank.

" there I. an error or omlaaion on tha labal,

croes out the Incorrect Information and fill In the

appropriate ltem(e). II you did not receive a

preprinted label, complete Section II through

Section IV.

8ectIon V. Locetion 01 Installation

If your Installation location add rea a ia dlf·

ferent than the mailing addresa, enter the tecatlon addreea of your Installation.

8ectlon VI. Installation Contact

Enter the name (Iaat and firat) and telephone

number of the person who may be contacted

negardlng Information containad In this report.

8ectlon VII. Cost Eatimatea for TSD Facilitlea

A. Enter the most recent coat estimate for

facility cloaure In dollars.

B. For dlspoeal facilities only, enter the moat

recent cost estimate for poat closure monitoring

and malntenence.

section VIII. Certification

The owner or operator of the facility or hia

authorized repreaentative must aign and date

the certification where indicated. The printed or

typed name of the person .signing the report

must also be included where indicated.

Note.-Slnce more than one page is required

for each report, enter the page number of each.

sheet In the lower right corner Be well as the

total number of pages.

ECY 030-12 INSTR.

EClF -273-

FACILITY ANNUAL REPORT

INSTRUCTIONS

A facility annural report must be completed by

owners or operatora of on-site or oN·site

facilities. A seperste sheet must be used for

each generator who brings his waste for treatment. storage, or diapoaal.

Nota.-Generators who ship dangeroua wasta

oN-aite to a facility they own or operate muat

complete this form inatead of the Generator Annual Report.

Section IX. Type of Report

Put an "X" in the appropriate box.

section X. Facility'a Identification Number

Enter the EPA/State identification number for

your facility.

section XI. Generator'a Identification Number

Enter the EPA/State identification number of

the generator of the waste deacribed under

Section XIV which waa received by your facility

during the reporting year. A aeparate ahe.t

muat be uaed for each generator. If the waate

came from a foreign generator, enter the EPA

identification number of the importer in thla section and enter the name and addreas 01 the

foreign generator in Section XV, Comments. If

the waste was generated snd treated, stored,

or disposed of at the same installation, leave

this aection blank.

Example:

XIV. WASTE IDENTIFICATION

I U

1'1: A. DESCRIPTION OF WASTE n. .r

Steel Finishing Sludge

Section XII. Ganerator's Name

Enter the name of the generator corresponding to the generator's EPA/ State identification

number in Section XI.

If the waste came Irom a foreign generator,

anter the nama of the importar corresponding to

the EPA identification number in Section XI.

Section XIII. Generator'S Address

Enter the addresa of the generator corresponding to the generator's EPA/State identification

number in Section XII. If the waste was

generated and traated, stored, or diapoaed 01

at the same installation, leave this section

blank. If the waate came from a foreign

generator, enter the addess of the importer corresponding to the EPA identification number in

Section XI.

Section XIV. Waate Identification

All information in this section muat be entered

by line number. A aeparate line entry ia required

for each different waste or mixture of waates

that your facility received during the reporting

year. Please make the proper notation of the

physical state and chemical nature of each

waste. The handling code applicable to that

wasta at the end of the reporting year ahould

be reported. If a diNerent handling code appliea

to portiona of the seme waste, (e.g., part of the

waste is atored while the remainder was

"chemically fixed" during the year), use a

separate line entry for each portion.

Section XIV-A. Deacription of Wsste

For dangeroua wastea that are lIated under

WAC 173-303, enter the Iiated name, abo

breviated if neceaaary. Where mlxturee of Iiated

wastea were received, anter the descrtptlon

which you believe beat deacribes the waste.

For unliated dangeroua wastes, enter the

description which you believe best deacribes

the waste. Include the specific manufacturing or

other process generating the waste (e.g., green

sludge from widget manufacturing) and if known,

the chemical or generic chemical name of the

waata.

-278'

D. AMOUNT OF WASTE

Section XIV-B. Dangeroua Waste Number

For listed wastea, enter the four digit

dangerous waate number which identlflea the

waste.

For a mixture of more than one Iiated waste,

enter each 01 the applicable dangeroua waste

numbers. Four spaces are provided. If more

space is needed, continue on the next IIne(s)

and leave all other information on that line

blank.

For unlisted dsngerous waates, enter the dangerous

waste numbers applicable to the waste. If more than

four spaces sre required, follow the procedure

described above.
4. Recycle (Reserved)

Section XIV-D. Amount 01 Waste

Enter the total amount of waste deacribed on

this line which you received during thia reporting yeer.

Units of volume may not be uaed for reporting

but muat be converted into one of the above

units of weight, tsking into account the appropriate denaity or specific gravily of the

waste.

section XIV-E. Unit of Meaaure

Enter the unit of measure code for the quenti·

ty of waate deacribed on this line. Units of

meaaure which must be used in this report and

the appropriate codes ere:

Monitoring Data

Do not attach monitoring dsts.

Unmanlfested Waste Report for facility owners

or operators who accept for trestment, storage.

or dlspossl any dangerous waste from sn

off-alte source without sn accompsnylng

manifesl.

Section XIV-A. Oeacrlptlon of Waste

Use ss many line numbera aa are needed to

describe the waste.

Important: Read Afl Instruction. se'or. Completing ThIs Form

The Unmanifested Waste report must be filled

out sccording to the directions for the Facility Annual Report except that: (1) blocks for which Information ia not available to the owner or

operator of the reporting facility may be marked

"UNKNOWN:' and (2) the following special Instructions apply:

Section IX. Type of Report

Put an ..x.. in the appropriate box.

Section XIV-C. Handling Code

Entar the handling code which describes the

statue of the waate on the date the report la

completed.

Section VIII. Cost Eatimatea for' Facilities

Do not enter closure or post-closure cost

satimates

Section XV. Comments

a. Enter the EPA/State Identification number.

name, and address, if known. If the transporter

ia not known to you, enter the name and chauf·

feur Iicenae number of the driver end the St.t.

snd licenae number of the transporting vehicle

which presented the waste to your facility. If

known.

b. Enter an explanation of how the waste

movement was presented to your facility: why

you believe the waste is dangerous; and how

your fscillty plana to msnage the wastes. Continue on a aeparate blank sheet of paper If ad·

ditional space Is needed.

Section XIV-D. Amount of Waste

Enter the smount of waste received, rather

than a total annual aggregate.

Section XIV-E. Unit of Measure.

Enter the appropriate unit of measure.

~'UNMANIFESTED:ASTE~EP~:-··---' INSTRUCTIONS

P

T

K

M

Unite of Mea8ure Code

(d) Biological Treatment

T67 Activated sludge

T68 Aerobic lagoon

T69 Aerobic tank

T70 Aneerobic tank

T7 1 Compoating

T72 Septic tank

T73 Spray irrigation

T74 Thickening filter

T75 Tricking filler

T76 Waate stabilization pond

T77 Other (apecify)

T78-79 [Reaerved)

3. Disposal

080 Underground injection

081 Landlill

082 Land treatment

083 Ocean disposal

084 Surtace impoundment (to be closed

as a landfill)

085 Other (specify)

Pounds ..

ShOr1 Ions (2000 Ibs) ..

Kilograms

Tonnes (1000 kg) ...

Section XV. Comments

This space may be uaed to explain or clarify

any entry. If usad, enter a crosa-reference to

the appropriate Section number.

Note.-Since more than one page ia required

for each report, enter the page number' of each

sheet in the lower right hand comer aa well aa

the total number of pages.

1. Storage

SOl Container (barrel, drum, etc.)

S02 Tsnk

S03 Waste pile

S04 Surfsce impoundment

S05 Other (specify)

2. Treatment

(a) Thermal Treatment

T06 Liquid Injection incinerator

T07 Rotsry kiln Incinerator

T08 Fluidized bed Incinerator

T09 Multiple hearth incinerator

Tl0 Infrared lurnace incinerator

TIl Molten aalt destructor

Tl2 Pyrolysia

Tt3 Wet air oxidation

T14 Calcination

T16 Microwave discherge

T18 Cement kiln

T17 Lime kiln'

Tl8 Other (specify)

(b) Chemical Treatment

T19 Absorption mount

T20 Absorption Ileid

T21 Chemical fixation

T22 Chemlcel oxidation

T23 Chemlcel precipitetion

T24 Chemi'cel reduction

T26 Chlorination

T26 Chlorinolysls

T27 Cyanide destruction

T28 Degradation

T29 Detoxification

T30 Ion exchange

T31 Neutralization

T32 Ozonation

T33 Photolysia

T34 Other (specify)

(c) Physical Treatment

(1) Separation of componenta

T36 Centrifugation

T38 Clarilicatlon

T37 Coagulation

T38 Decanting

T39 Encapsulation

T40 Filtration

T41 Flocculation

T42 Flotation

T43 Foaming

T44 sedimentation

T46 Thickening

T.48 Ultrafiltration

T47 Other (specify)

(2) Removal of specific componenta

T48 Absortlon - molecular sieve

T49 . Activated carbon

T60 Blending

T51 Catalysis

T62 Crystallization

T63 Dlalyaia

T~ Distillation

T66 Electrodialyaia

T66 Electrolysis

T67 Evaporation

T66 High gradient megnetic separation

T69 Leaching

T60 Liquid ion exchange

)"81 Liquid-liquid extraction

T82 Reverse oamosis

T83 Solvent recovery

T64 Stripping

T86 Sand fliler

T68 Other (apecify)

8ec:tIon XlV-C. Handling Code

Enter one handling code lor each waste line

entry. Where seversI handling steps have

occurred during the year, rsport only the

handling code representing the wsste's ststus

st the end 01 the reporting year or its linal

disposition. Handling codes are given below:

ECLO -273- ECY 034>12 INSTR.
Pleae pt1n1Of l7Pe wfth ELITE type (12 ehareel... per Inch).

. --,

sc.te of TSD FACILITY ANNUAL DANGEROUS WASTE REPORTIUNMANIFESTED WASTE REPORT

Washington

Departmenl I I. Type of Dangerous Waste Report of Ecology e" I 0 I FACILITY ANNUAL REPORT

THIS REPORT FOR YEAR ENDING DEC. 31, 11 19\ I

PLEASE PLACE LABEL INTHIS SPACE

I

01 UNMANIFESTED WASTE REPORT

FORM THIS REPORT IS FOR A WASTE

5 RECEIVED ( month, day & year): ; !., I 11 191 I

INSTRUCTIONS: You may have received a preprinted label attached 10 the front of this pamphlet; affix it in the designated space above. If any of the

Infonnalion on the label is incorrect, draw a line through it and supply the correct information in the appropriate section below. If the label is complete and

correct, leave Sections II, III, and IV below blank. If you did not receive a preprinted label, complete all sections. "Facility" means a single site where

dangerous waste is generated, treated, stored, or disposed.

II. FACILITY EPA/STATE 1.0. NUMBER

I I I I I I I I I I I I

III. NAME OF FACILITY

I I I I I III I I I I I I I I I I I I I I I I I I I I I I I I ! I ! I I I

IV. FACILITY MAILING ADDRESS

Streetor P.O. Box

I I I I I I I I I I ) I 1 I I I I I I I I I I

I

I ; I I I I I I'

Cityor Town m Zip Code

r 1 r 1 I I I 1 1 1 I 1 I I I I 1 1 I I I I I i I I I : \ I

V. LOCATION OF FACILITY

StreetorRouteNumber :

r 1 I -1 I 1 I I I I I I I 1 1 I I I I 1 I I I I I I I I 1 1 I

.- ..

Cityor Town m Zip Code

I I I I I I I I I I I I 1 I I I I I 1 1 I I I I I I I I I I

VI. FACILITY CONTACT

Name (IaatandIirst) PhoneNo.(area code & number)

r 1 I T I II I I I I I I i I I I , I I I I

,

! I I I I I :. I I I ! , !

j T 1 1 i !- , ! i ,

VII. COST ESTIMATES FOR FACILITIES

A. COST ESTIMATE FOR FACILITY CLOSURE B. COST ESTI~.~ATE FOR POST CLOSURE MONITORING I

AND MAINTENANCE (disposal facilities only) I

$1 I I II I I II I I I 1$1 . I i I

: I I : I I! I I . , "I I it;

XIII. CERTIFICATION

I certify under penslty ot tsw thst I hev» personally examined and sm familiar with the informstion submitted in this and sll ettecnea documents, snd thst

bssed on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, sccurste,

snd complete. I am aware that there are significsnt penalties for submitting false information, including the possibility of fine and imprisonment.

PRINT ORTYPE NAME SIGNATURE DATE SIGNED

eey 0»12

ECLH ·270- PAGE_1_0F _
----------------

..---:--------------..• '--------------....,

FACILITY ANNUAL REPORT /UNMANIFESTED WASTE REPORT

, , I W I

! X. FACILITY'S EPA/STATE I.D. NO. : ! :. I !; I

! 2. REVIEWED BY

!

Ll. DATE RECEIVED

FOR OFFICIAL

USE ONLY

(ITEMS 1 AND 2)

Xl. GENERATOR'S IDENTIFICATION NUMBER

I I , I I . ;

BOX. CITY, STATE" ZIP CODE)

XII. GENERATOR NAME (specify) -_.. ~_._---'------------

XIV. WASTE IDENnFICATION

N PfI~ IChemica':

State I Nature ,

N B S-Solkl

EEL-Liquid Q=Orglmc .

A a-Sludge I-Inorganic

'--,-_~ .___ ,: i J ! 1 !

--------------------f---,-.---,-.~-. --------- -H---+-++.11

: -~

I I :' I ! Ii: ; . ! ! I

I I

D. AMOUNT

OF

WASTE

, ! , ! , I I

I ,

I i ,

i

I

i

I , ,

i i i

I I

I I

I

I

I

I

I ,,

! i ! I i

I i

! i I

I

ii' ! I I i , ; Iii

I

!

c. B. DAtoiGEROUS HANO·

WASTE NUMBER LING

METHOO

(see instructions) enter code)

:

, -,-- I i I I I I

I I I • I I

, -----,- i i I

I ! I I -,- I

i I

i I I ! , ! I

; i , i I

I , -- :

:

, ,

i i i

!

: I

A. DESCRIPTION OF WASTE

I

!

i

I

I -

I

I

I

I

!

I -

I

,

I

I

I

I

i

!

i

i

,

, -._--

i

I

r

4

3

2

1

8

5

9

12

11

10

13

14

15 ~-----------.- ! I

XV. COUMENTS (ENTER INFORMATION llY LINE NUMBER SEE-INSTRUCTIONS)

.----~-----"--------- ...------.---.------- .- ---------------.--.----.--. - -------.----.----------------i
GENERATOR ANNUAL "DANGEROUS WASTE REPORT

FORM 4

ECY 030-28 IN8TA.

1/82

I
FORM 4

GENERATOR ANNUAL DANGEROUS WASTE REPORT INSTRUCTIONS

Units of volume may not be used for reporting

but muat be converted into one of the above units

01 weight taking into account the appropriate denaity or specific gravity of the waate.

seellon XIII-O. Unit of M.aaur.

Enter the unit of measure code for the quantity

of waste described on this line. Units of measure

which must be used in this report and the appropriate codes are:

seellon XIII-C. Amount of Waate

Enter the smount 01 this wute you shipped to

the Iscility identilied in Section X and include the

weight 01 contelners if leff st the treatment,

storsge, or disposal facility.

seeUon XlV. Commenta

This space may be used to explain or clarity

any entry. 11 used, enter a cross reference to the

appropriate Section number.

Note.-Since more than one page Is required

for each report, enter the page number of each

sheet in the lower righl corner 88 well as the

total number of pages.

P

T

K

M

Units of measure

section XlII-B. Dangeroua W.at. Number

For listed wastes, enter the dangerous waata

number which identifies the waste.

For a mixture of mora than one listed waste,

enter each of the applicable dangeroua waste

numbers. Four speces are provided. 11 more

spece is needed, continue on the next line(s) and

leave all other information on that line blank.

For unlisted hazardous wastes, enter the

dangerous waste numbers spplicable to the

wsste. If more than four spscss sre required,

follow the procedure described above.

Pounds

Short ton. (2,000 lb.)

Kilograms

Tonne. (1.000 kg)

All Information in this section must be entered

by line number. Each line entry will deacribe the

total annual amount of each waate shipped to the

facility identified in Section X. above.

section XII. FlIClllty Addre..

Enter the sddress 01 the of the lacility corresponding to the lacility's State/EPA identifica·

tion number in section X.

section XI. Faclllty Name

Enter the name 01 the facility corresponding to

the facility's State/EPA identification number in

Section XI.

section XIII. Wallte Identltlcatlon

section X. F.ctllty'a ld.nUflcation Number

Enter the State/EPA identificstion number of

the :acilit) 10 which you sent the waste described

below in section XIII (s separate sheet must be

used lor esch fscility to which you sent hazar'

dous waste.)

Section XIII-A. Deacrfptlon of Waate

For hszsrdous wastes thet are listed under

WAC 173-303, enter the listed name, abbreviated

if necessery. Where mixtures of listed wsstes

were shipped, enter the description which you

believe best describes the wsste.

For unlisted hazardoua waste identified under

WAC 173,303, enter the description which you

believe best describes the wsste. Include the

specific manufacturing or other process

generating the waste (e.g .. green sludge from

widget manufacturing) and, il known, the chemicsl

or generic chemical name of the waste.

Important: Read all instructions belore completing

tin report. Thla report ia to be completed by

generators who ship their wute off'aite to

faclllttea which they do not own Or operate.

section Y. Location of Inatallation

" your Inatallation location address is different

than the mailing address, enter the location ad·

dre.. of your inatallation.

Section VII. Tranaporlation Semc.. Uaed

LIat the EPA/State identification number of

each transporter whose lIervices you used during

the reporting year.

SectIon L FlI In ltle reporting ,Nr for INs report.

s.ct/orl • ftIIlJ S6ction IV. Insla/llJliOt! I.D. Number,

Name at In.tan.lion, end InslsllaliOt! Mailing Ad·

dreN

" you received a preprinted label trom EPA or

from the Department of Ecology, sMach it in the

epace prcMded and leave sections II through IV

blank. " there is an error or omillaion on the

label, cnlBB out the incorrect inlormation and fill in

the appropriate item(s). 11 you did not receive a

preprinted label, complete Section II through seetion IV.

SecUon Vlfl. Certltlcatlon

section VI. lnalallaUon Contact

Enter the name (Iut and firat) and telephone

number of the person who may be contacted

regarding information contained in this report.

section IX. Generator', ldenUfication Number

Enter your EPA/State identification number.

'The generator or his authorized representative

muat sign and date the certification where in·

dlcated. The printed or typad name of the peraon

algnlng the report must also be included where in·

dlcated.

Not••-Since more than one page may be reo

qulred lor each report, enter the page number of

each ~t in the lower right comer as well as

the· total number of psges.

Example: -27&-

XIII. WASTE IDENTIFICATION d B. D...NGEROUS ...

.... DESCRlPTlON OF W"'STE NUMBER

W"'STE D. AMOONTOFW...STE ~~ ...instruction.)

KOllO KOlll _4 1 2 4 8 T 1 Steel Finishing Sludge KOll2 KOll3 -

2

IK-O-lI-4

Ea.C -213- fCY 030-28 IISTR.
J.,

Section XIV-D. Amount 01 Waate

Enter the total amount 01 waate deacribed on

thia line which you received during thia repor·

ting year.

Unita 01 volume may not be uaed for reporting

but must be converted into one 01 the above

units 01 weight, taking into account the appropriate density or apecific gravity 01 the

waate.

SecUon XIV-E. Unit of Meaaure

Enter the unit 01 meaaure code for the quantity 01 waate deacribed on thia line. Unlta of

measure which must be uaed in thia report and'

the appropriate codes are: .

Unmanlfested Waste Report Instructions

Unmanifested Waale Report lor lacility owners

or operatora who accept for Ireatment, atorage,

or disposal any hazardous waate Irom an

0"- site source without an accompanying

manifea!.

SecUon XIV-E. Unit 01 Meaaure.

Enter the appropriate unit 01 measure.

Section VIII. Coat Eatimatea lor Facllitiea

00 not enter cloaure or pest- cloaure coat

eatimatea

Section IX. Type 01 Report

Put an "X" in the appropriate box.

Section XIV-A. Oeacription 01 Waate

Uae sa many line numbara aa are needed to

deacribe the waate.

Section XIV-C. Handling Code

Enter the handling code which deacribea the

atalus 01 the wsate on the date the raport ia filed.

Important: Reed All lnetructlona Before C0mpleting ThIs Form

The Unmanlfeated Waate report muat be filled

out according to the directiona for the Facftlty Annual Report except that: (1) blocka for which information ia not available to the owner or

operator 01 the rapot1ing lacility may be marked

"UNKNOWN," and (2) the lollowing apeclal inatructiona apply:

Section XII. Commenta

a. Entar the State/EPA Identification number,

name, and addreaa 01 the tranaporter, if known.

If Ihe trsnaporter ia nol known to you, enter the

name and chau"eur license number 01 the driver

and the State and Iicenae number 01 the

tranaportlng vehicle which preaented the waate

to your lacility, If known.

b. Entar an explanation 01 how the waata

movement waa preaanted to your facility: why

you believe the waste is hazardoua; and how

your lecility plana to manage the waatea. Continue on a aaparale blank aheet 01 paper II additional space ia needed.

Section XIV-o. Amount 01 Waate

Enter the amount 01 waste received, rather

than a total annual eggregate.

Monitoring Data

00 not attach monitoring data.

P

T

K

M

Code

Pounds

Short tona (2000 lbs)

Kilograms .. _

Tonne. ('000 kg)

Units of Measure

(d) Biological Treatment

T87 Activated aludge

T88 AtIl'Obic lagoon

T89 Aerobic tank

T70 Anaerobic tank

T71 Compt'ating

T72 Septic tank

T73 Spray irrigation

T74 Thickening filter

T75 Tricking filter

T7S Waate atabilization pond

T77 Other (apecify)

T78-79 [Reaerved)

3. Dlapo..1

D80 Underground injection

081 Landlill

082 Land treatment

083 Ocean diapoaal

084 SUrface impoundment (to be cloaed

88 a landfill)

085 Other (apecify)

SecUon XV. Commenta

Thia apace may be uaed to explein or clarity

any entry. II used. enter a croaa-relerence to

the appropriate Section number.

Nota.-Since more than one page la required

lor ea~r -eport, enter Ihe page number of each

aheet in the lower right hand comer aa weli aa

the total number 01 pages.

For unIIated hazardoua waatea, enttll' the

dangeroua waate numbera applicable to the

_ete. " more ltIen four apecea are requlrfld,

follow the procedure deacribed above.

1. -...

801 Container (barrel, drum, etc.)

802 Tank

803 Waite pile

804 Surface impoundment

S06 Other (apecify)

a. TrNtment

(a) Thermal Treatment·

T08 Liquid injection incinerator

T07 Rotary kiln incinerator

T08 Fluidized bed incinerator

T09 Multiple hearth incinerstor

TtO Infrared furnace incinerator

Tt1 Molten Hit deatructor

Tt2 Pyrolyals

Tt3 Wet air oxidation

Tt4 Calcination

T15 Microwave diacharge

T18 Cement kiln

T17 Lime kiln

T18 Other (apecify)

(b) Chemical Treatment

T19 Abaorption mount

T20 Abaorption lield

T21 Chemical fixation

T22 Chemical oxidation

T23 Chemical precipitation

T24 Chemical reduction

T26 Chlorination

T28 Chlorinolyaia

T27 Cyanide deatruction

T28 Degradation

T29 Detoxification

T30 Ion exchange

T31 Neutralization

T32 OzonaUon

T33 Photolyala

T34 Other (specify)

(c) Phyalcal Treatment

(t) separation 01 componenta

T36 Centrilugation

T38 Clarification

T37 Coagulation

T38 Decanting

T39 Encapaulation

T40 Filtration

T41 Flocculation

T42 Flotation

T43 Foaming

T44 Sedimentation

T46 Thickening

T48 Ultraliltration

T47 Other (specify)

(2) Removal 01 apecific componenta

T48 Abaortion-molecular aieve

T48 Activated carbon

TIIO Blending

T151 C8talyala

T152 ery.tallization

T153 Dla/yala

T154 Dl8tlDatlon

Tl56 EJectrodlalyaia

Tl5e EJectrolyaia

TIl7 . Evaporation

T158 HIgh gradient magnetic ..paratlon

T158 Leaching

Teo Uquld Ion exchange

T81 Liquid-liquid axtraction

T82 Rav«M_1a

T83 Solvent recovery.

T84

T8l5 Sand filter

TI8 Other (epeclfy)

IectIoft X1Y-c. Handling Code

enter one handling code lor each waate line

entry. Whtll'e HV8fal handling atepa have

occurred during the year, report only the

handIlng code representing the waate'a status

at the end of the reporting year or ita Ilnal

~ion. Handling codes are given below:

Ea.G -273-
.....pmtOl'tJpe _EUTE tJpe(12 lndl).

St.ate01 GENERATOR ANNUAL DANGEROUS WASTE REPORT

WulWllton

8 I. THIS REPORT FOR YEAR ENDING DEC. 31, 11 19 I I

.l' PLEASE PLACE LABELINTHIS SPACE

Form

4

INSTRUCTIONS: You may have received a preprinted label attached to the front of this pamphlet; ... Hix it in the designated space above. If any of the

Information on the label is incorrect, draw a line through it and supply the correct information in the appropriate section below. If the label is complete and

correct. leave Sections II, III. and IV below blank. If you did not receive a preprinted label, complete all sections. "Facility" means a single site where

hazardous waste is generated, treated, stored, or disposed of.

II. FACILITY STATE/EPA I.D. NUMBER

I I I I I I I I I I I I I I I

III. NAME OF FACILITY

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I ! I I I I I I

IV. FACILITY MAILING ADDRESS

Street or P.O.Box

I I I I I I I I I I I I I I I I I I I I I I I I I I I I

City or Town State Zip Code I

I II I I I I I I I I I I I I I I I I I I I I I I I I I' I I

V. LOCATION OF FACILITY ,:

Street or RouteNumber

I I I I I I I I I I I I I I I I I 1 I 1 I I 1 I I I I I

CltyorTown State Zip Code I

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I ,

I

VI. FACILITY CONTACT

Name(last andfirst) PhoneNo.(area code & number)

I I I I I I I I I I I I I I I.: I I I I I I I I I I I I I I

I- I I I I- I I 1I I

VII. TRANSPORTATION SERVICES USED

VIII. CERTIFICATION

'certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents. and that

I based on my Inquiry of those individuals immediately responsible for obtaining the information, , believe that the submitted information is true. accurate•

• nd complete. I am aware that there are signlficanf penalties for submitting false Information, Including the possibility of fine and imprisonmenl.

..

-- A. PRINT ORTYPE NAME B. SIGNATURE C. DATE 8lONED
FORM 4 GENERATOR ANNUAL DANGEROUS WASTE REPORT

FOR OFFICIAL 1. DATE RECEIVED I-I I 1-1,1 9 11 IX. GENERATOR'S IDENTIFICATION NUMBER

USE ONLY

I 11 I I 1 IIi I I I (ITEMS 1 AND 2) 2. RECEIVED BY

X. FACILITY'S IDENTIFICATION NUMBER XII. FACIUTY ADDRESS (STREET OR P.O. BOX, em, STATE & ZIP CODE)

I I I I I I I I I I II

XL FACILITY NAME (SPECIFY)

lOL WASTE IDENTIFICATION W

: B. DANGEROUS I C. AMOUNT ~'w8 LM

I

a:U

A. DESCRIPTION OF WASTE WASTE NUMBER OF l5:>a: I • "'w

: : WASTE "'-e'" (see instructions) ~wz~!!!

I !

• i i I i

1 I i

2

3 I

I

i I i 4 I I I I

! ! 5 I

6

7

8

..

10 I

11

I I

12 I I , I I I

!

lOY. COMMENTS (ENTER INFORMATION BY UNE NUMBER-SEE INSTRUCTIONS)

,

.
·-..I wI}

/;t3

TSD FACILITY ANNUAL DANGEROUS WASTE REPORTOR

UNMANIFESTED WASTE REPORT

(Required by WAC 173-303-390( 1) &(2) )

FORM 5

Return Completed Forms To:

State of Washington

Department of Ecology

HAZARDOUS WASTE SECTION

ATTENTION: ANNUAL REPORTS

MS-PV·11

Olympia, WA 98504

• T.S.D FACILITY MEANS ANY FACILITY THAT TRANSFERS, TREATS, STORES OR DISPOSES OF

DANGEROUS WASTE (DW) OR EXTREMELY HAZARDOUS WASTE (EHW).

DANGEROUS WASTE AS USED IN THIS FORM INCLUDES ALL DW AND EHW.
FORM 5

FORM 5

DANGEROUS

INSTRUCTIONS FOR

WASTE' REPORT OR

COMPLETING TSD

UNMANIFESTED

FACILITY ANNUAL

WASTE REPORT

GENERAL INFORMATION

Thl. lorm i. 10 be .ubmilled to tne oep.rtmen, of

Ec:olOi/Y ..,eQui,ed by Ihe oenoerou. We.'. R.gul.·

tiona under h'fO circum.tance.:

1. A••n .nnu.' report lor T.S.D. l.cUltie. by Me,ch 1

01 the ye.r tollo",'nO Ihe reponino ye.r. or

2. A••n unm.nih'.'eo .....,. ,eport tor T.S.O. 'ecilfll••

who .ccep' • d.noe,ou. or extremely h...rOoue

w••te lhel i. unm.n,te.'ed. The ,eport rnust be

.ubmltted wilhln 15 d.y. 01Ih. recelp, 01rne unmanl'••,.0 ...e.le.

8eca"•• more th.n one Report Fo,m m.y be

nece•••"y ph...e m.ke ••ve,.' bl.nk copiee .nd _erthe p.oe number and Ihe 10t.1 numbe' ot p.oe. in

the lower ,ighl h.nd come' ole.ch p.ge.

Inlorm.lion reQuired In .ny annu.1 repol'1 torm by Ihe

Oep.rtmenl of ECology m.y be cle..llteO confid.n'i.1

by the ,eportlno compeny, p,ovloeo, Ihe comple'"O

lorm ie .ccomp.n,ed by • cover lelle' which .pecllie.

whlcllllltormation I. contldenlial.

If the dep.rtmen, i. reQue.,ed 10 rele.ae inform.tion

contalneo in • confioenli.1 ,eport, Ihe d.pertment ...ill

noIlty you. Any inlormalion conI. ,ned in eny report not

claimecl to be confidenti.1 may be releeaed ...Ithout

notice.

Section I. Type of Dangerous Waste Report

A. TSD FACILITY ANNUAL REPORT

For o...ner. or oper.'or. ot t.cllilie. Ih.t

t,ane'er, tre.t. elore, or di.po•• of d.noerou.

w.ale Check 80. "A" .nd fill In the reporting ye.r

oIlhl. ,eport.

HOTE

Section 5A-Locetlon of TSD Fecillty

It the locetion at your T50 facility la dIfferent .hen tne

mailing 800'886, enter the rocsnon edd'8&8 of your

TSO t.cility.

Section 58 - County of TSD Facility

Enter Ihe counly ,n _ich your TSo t.cility i. 10c.teO.

Section 6. TSD Facility Contect

En,er the n.me (1••' end fir.t) .no lefephone

number at the pereon who mey be contacted

regarding Informstion conramed in thle repOrl.

Section 7. COllt Estimates for TSD Facilities

A. For all TSO I.cititiee ent.r Ihe most rec.nl

cost e.tim.'e lor TSD t.cility croeure in Ooll.r•.

8. For di.po••' lacililie. only, enter the mo.,

recent cost estimate for post·cl08ure monitoring

end me int en.nee.

Section 8. Certlflcetlon

The o...ner or op.r.tor ot Ihe TSD f.cility or

hie authorized reD,eaentattve must sign and

dete ~he certlhcation where Indicated. The

prlnleo or typeo n.me 01 the per.on .'onong lhe

report muet alao be inclUded where inOicated,

I.

!

Section 12. Generator', Name

Enler the neme of the generator corresponolng 10 Ihe gener.'or·. EPA/St.,e ,<lantltic.lion

number in Sec.ion 11.

If Ihe west·s came trom • fOleign gen.ralor,

enter the name of the importer correaponding to

the EPA Identific.tion numDar In Section' 1.

Section 13. Generator's Addrels

Ent.r the .00,.e. of the oenerelor corre.pon·

o,ng '0 tho OMer.,or·. EPA/SI.te identllication

number In SeclIon 11. If the waste wae

generated end HeSted, a.ored, or dlepoaed of

a1 tne Ierne Inal8l1SlIon, leave thi, aecllon

blank. If 1he wasle came from a for.ign

gener.lor, enter fhe eddre.a ot the Imponer

corre.pondlng to Ihe EPA/SI.te ioentiflcalion

number in Sect ion t 1.

Section 14. Waste Identification

All in'ormetioo in thia section muat be entered

Dy line number. (.ee eumple below) A

.eperale line entry i. 'equired tor e.ch <llffe,ent

.....'e or mixture of .....te. that your lacllny

receiveo ourino the reporting yeer. Pleeae m.ke

the proper not.,ion ot the phy.'ce' .t.,••nO

chemic.I n.ture ot e.ch te. The h.ndlinO

cooe .pplic.ble 10 th., a.'e .t Ihe eno ot the

report 109 year .houlO De reporteo. It • <lifte,ent

hanoling code .ppliee 10 ponion. 01 Ihe .ame

"aate, (e.g .. pen of the w••'e I••tor.O while

the .emainder wa! "chemically filed" during the

ye.,), u.e a eep.,.Ie line entry for e.ch por·

tion.

Section 9. TSD Facility's Identification

Number

Enter 'he EPA/S'.le ioenlific.tion number for

you, TSO t.cilify.

; i ; :1 10 i6 !J io f P

·'-0;'--;-+--

Section 14A. Description of Wilste

For oangerous .....Ie. lhat .re Ii.'eo under

Chapter t73-303 WAC. enler Ihe Ii.leo n.me.

abbreviated it necessary.

.. DESCAIPTfOtij Of WAST(

EXAMPLE

EMISSION CONTROL OUST FROM 1s·o i' .0 .' .. ' ...- •.-.. ow STEEL PROOUCTIO"!. -. - - - -_.. ----.-,----.t-- • I ' , ' ,

• I .. _ _

,~ G

._ ..,_. _....-....- .. I ~".ull C~.I

l =I " : ......... ; 1 111' '

::' \.~_ !o.o..._

,10........ ;'·-..-:

Fo, TSO Annual Repon. only

I) If you .re only. gene,alo, 0' d.nge,ou. or e.·

tremely hal.rOoua .....Ie (OW /E,",W). you mu.t

ClOIftP'ala Form A.

U) If you .,e a gene,.lor Owninll or operalino your

0-T80 tacility ano you man.ge ALL OW /EW,",

~e,ated by you or Olhe'. on·.lle. you mu.t com·

plete Fo,m 5 onty.

UI) II you .re • gener.to, who o...n. or oper.'e.

your own TSO I.cility.nd eny ot Ihe OW / EHW you

QeR8l'ale or meneoe i. aub.eQuently .hippeo 011·

alte to enolher TSo lecllny (...helher o...n·

eel/opereled by you or .nOlher p.reon). you muel

complele bOlh Form. 4 end 5.

lY) II you o...n or operale e TSD lacilily only .nO

ALL OW /EHW .,a meneoeo on·alle, you mu.' complele Form 50nty.

8. UHMAHIFESTEo WASTEREPORl

For 'acUity owners Of operata,. who accept tor

trana'.r, tr.atment, Ilorage, or diepoael any

(I.noeroue w ••'. from .n oU·.lte lource w"houl en accompanying m.nltelt. check Bo). "8" end till in

the d.'. the ..,•••• wee recelyed 81 the facility.

Section 10. Type of Report

PUI an "X" In the appropnst& bo,,-.

For unlis1ed dangerous waltea or mixtures 01

Qefloe'OU8 w8ates, en'er the description Which

you believe beat describee the waSle. ,"elude

me apecitic manufaclurino or other process

generating the wllele (e.g .. o.een aludge from

wlogel manulecturlOC) end If known. the

Ch~mlC81 or QbMHIC chemical neme ot the

waster.

Section 2 thru Section 4. TSD Fecillty

Information:

II you racalvao a preprinleO I.bel trom Ihe

Depanmant ot EcoloOY, .lfi. It in the .pece pro·

videll ano l118ve Sections 2A, 3, .nO 4 bl.nk. It

there i. an error or oml..ion on the lebel, cros.

out tha incortect into,m.tion .no fill in the .p.

propriale item(.). It you OiO not rec.ive e

preprinled label. compl.te Section 2 Ihrouoh

Section A.

Section 28-TSD Facility Stendard Induetrlal Claaalflclltion (SIC) Code(B):

Llallha SIC cod....hlch be. I lle.c,lbe. your bu.ine..

actlvlllea. U.. the U.S. Oep't, of COntmerce "SI.ndarll

lnduat,..1Cle.allicalion Manual". II more th.n ona SIC

code I. applicable 10 yoUf aClIY"laa, lIal alt SIC code.

wNch be., daacrtbe your bu.lne...

Section 1 ,. Generator's Identification

Number

Enter the EPA/ Stele ioentificBtion number of

Ihe gener.tor ot Ihe .....te oe.crlbeo unoer

Section 14 which "'B. ,eceiveo by your TSO

'.cilify ourlno Ihe reponino y.ar. A ••perat,

ah.et muat be u••d 'or each generator. It the

welle ceme trom B torelgn generalor, enter Ihe

EPA identification number 01 the imporler in this

section and enlel the neme end eddre6e of Ihe

foreion oener.tor In Seclion 18, (Comment•.) It

the .....te wea oener.t.o .no tr••teo••IoreO.

or dlspoaed ot at the ••me ineteflalion, en'er

your TSO I.clllly number.

Section 14-B. Handling Code

Enter one handline code tor 8aCh wasle line

enHy Where a~Y8'81 handling steps heY8

occurrec Ourino the year, report only the

handling code represtlnting the weete's St6tU8

S11he end of the reponing yeel or ite final

di!posilion. Handling codes are oiven below:

1. Storage

SOl' ContBiner (barr.l, drem. etc.)

502 Tank

S03 Weele pile

S04 Surf.ce ,mpounOmenl

505 Olher (.pecity)

2. Treatment

(a) Thermal Treatment

T08 liquid Injection Incine,.to'

T07 Rot.ry kiln Incln.,.to,

ecy 030-12 IHSTR. • DANGEROUS WASTE AS USED ON THIS FORM AND INSTRUCTIONS INCLUDES

BOTH DANGEROUS AND EXTREMELY HAZARDOUS WASTE.
Toa FIUldi,ad bed ineinaralor

TC!'I Multiple h.."h inc,nerator

T10 Infrared furnace inc;n.r••or

Tt I loAoltan ult OeatruClor

T t2 Pyrolya..

Tt3 Wa' air o.ioatlon

Tt4 Calcination

T 15 loAicro..ave d,acharge

Tt8 Camel'll kiln

T17 Lome kiln

T 18 Other (apacily)

(b) Chemical Treatment

T 19 Abaorptlon mounO

T20 Abaorption rielo

T21 Cnamlcal" ..tion

T22 ChemIca' 0..oe1l0n

T23 Chemical preclpnation

T24 Chemlcel reduction

T26 Chlorinet,on

T26 ChlorinOlyaie

T27 Cyenlde Oeetruction

T28 Oegreoallon

T29 Deto.il,ealion

T30 Ion eachange

T31 Neutreltzeloon

T32 O,onalion

T33 Phololyaie

T34 Other (apeeify)

(C) Physical Treatment

(1) SeparaUon 01 eomponan..

T35 Cen,,,fugalion

T38 Clarification

T37 Coagulation

T38 Deeenling

T39 Eneapeulellon

T40 Flltrelion

T41 Floeculelion

T42 Floletion

T43 Foemono

T44 Sedimenlelion

T46 Thiekening

T.6 Ultrefiltretion

T47 Olher (.peeify)

(2) Removel 01 epecitic componente

T48 Abson;or,-mo'ecuiar 8;e"'6

T49 AClivated earnon

T50 Blending

T6 I Cetalyai.

T62 Cryalallizalion

T63 Diely.ia

T~ Dlatillalion

T66 Electrodialyeie

T68 Electroly.ie

T67 EveporaUon

T56 High gradient magnetic leperation

T69 Leecnlng

T60 LiQuid ion e.cnange

T6 I liQuid-liQuId eatrection

T62 ReverIe oemosis

T63 Solvei'll recovery

T~ Stripping

T66 Send filter

T6e Other (.oec·lly)

(d) Biological Treatment

T87 Act.veted .luOge

T8a Aerobic 'ogoon

T69 Aerobic ten.

T70 AneerObic ,.nk

T71 Composting

T72 Sepllc len.

T73 Spr.y ir"g.IIon

T74 T.nickenlnc fill.r

T75 Trickline IIIter

T76 Wea'e stabilization pond

Tn Other (.pacify)

T76-79 (Reaervad)

3. Disposal

080 Undergrouno in,eetion

081 LendfiU

082 Land Ireetmenl

083 Ocean d,.po.al

064 Surts ce impoundmenl (to be cloeed

80 • landfill)

085 Other (.peclly)

Section 14C. Dangeroua Waate Numb.r

For luned w8stes. enter thflotour digit dangerous

waSle number W't1ich identifIes the waBle.

For e mixture of more than one lieteO wasle. enler

Bech of the applicable oengerouB weste numbers.

Four spaces are pro¥fdeo It more spece is needed.

contmue on the next hne(a) and 198"8 ell other infof'

mauon on thet line blank.

For unlisted dangerous WHSlee. enter the generic

osngeroua waSle number, applicable to the waate

(reI. WAC t73·303·104).11 mora than tour apaee.

are reQuireO. toUo.. the procedure deacribed above.

Section 140. Waste Deaignatlon

Indicate whethe, Ihe ""ule i. daeignated dengeroue

or extremely hazert'ou6 8S determined under WAC

173·303-010Ihrough t 73·303·104. Enter the correaponding ecce.

OW-Dengerou. Weele

EHW-E.tremely Hazerdoua Weete

Section 14E. Amount of Waste

Enter the 10lal amount of "esle by ..eight

Oeaeribed on this line whieh you reeeived during

Ihi. reporting year.

Unit. of volume IIlA'Y NOT be ueed for

reponing but cen be conv..ned inlo one of lhe

un't. 01 ..eight belo.., leking Into eecount the

eppropriate denallY or .pecific gravity of the

waIte.

Seetlon 14F. Weight Code

Enter the Weigh' Coo~ lor the. Quantily of

weste deeCflbf'd on thIS hne. Unite of weight

vwrucn must be u8tld In thil!l repon and the ap·

propriate cooes afe;

COd~

Pounoa

5"on ton~ (2OCJO lbe.)

K,logr.rnf,

TOl'lnee. (1000 kg)

Section 15. Tranaporter Und

TO BE COIoAPLETEO ONL Y IF THIS FORM IS

USED AS AN UNIoAANIFESTED WASTE

REPORT.

Section 16. Comments

Thie apace mey be uaed to e"plain or clerify

any entry. It uaed. emer 8 cross-ref.rence to

Ihe eppropriate SeClion num~. For commenle

relaled 10 Section 14. enler the iine number.

SPECIAL INSTRUCTIONS FOR

UNMANIFESTED WASTE REPORT

An Unmanltaeled Waale Raport muat be .ub·

mllleO ..ithin 16 O.y. el1er recaifll ot lhe w.ale

by lecility o..ner. or operalOn whO .acept lor

trenafer. trestmen1, atorage. or cJi.~.1 any

osnoeroua waste trom en ott-ene eource wtthou'

.1'1 accompanying menifee!.

Imporlant: Raed All Ina'ructlona Befora C0mpleting Thla Form

The Unmenile.ted Weste repon muat be fiHed

out .ccordong 10 the direclion. lor the F.cility An·

nual Repon exeept thet: (1) blocka tor wnich In·

lormation i6 not evailsbl6 to the owner or

operator aline reponone taeillty may be mlOn.ed

"UNKNOWN," and (2) the tOllowing apeciel in-

.tructione apply:

Section 7. Co.t Eatlmates for Facllltiea

00 not enler eloaure Or poat -eloeure coat

estimatea.

Section 14A. Description of Waate

Use 86 many line numbers 8S 8'e needed to

oescribe the W88te.

Section 14C. Handling Code

Enter the handling eooe whieh oe.cribaa Ihe

atatu. of Ihe ..esle on the dete Ihe repot! ie

eompleled.

Section 14E. Amount 01 Weat.

Enler tha amount 01 ....te reeeived. r.that

Ih.n • total annu.1 aggreg.ta.

Section 15. Tranaporter Ueed

Enter the EPA I Stele identificelion number,

neme. end addreoa, it known. of the

TRANSPORTER wno delivered lhe Unmanileeled

Weete 10 your tecility. It the Irenaporter i. not

known to you, enter the name and chauHe"r

Ilcen.e number of the driver eno the State and

licenee number of the trenepo"ing vehicle wnieh

preeenied the ""e.te 10 your lecilily, it known.

Section 16. Commenta

Enter en explanalion of how the wel'te move·

mel'll .... preeented 10 your tecill!)': why you

b@lie¥e the waste is dangeroue. why the weate

WSB unmBnltesled; lind how your facility plana

to menRge the ",eolfta. Continue on a ••parate

blenk .heel 01 pape' II additional ep.ce Ie

neeOed.

EClG -642- Eey 03C>-12 IHSTR.
...-__-------------r-------------------r--,-----------------... TSD FACILITY ANNUAL O,...i'.JGEROUS WASTE REPORT/UNIVIANIFESTED WASTE REPORT

12. GENERATOR NAME (.peelfy)

1~. WASTE IDENTIFICATION

H

l U

1 M H B

E e

R

Pllyalcal I Cn-mlcal ;

Stale I Nal,,'. ,

S-Solttl I ; L-ltQuiG \ o· Oroanlt i

G"s'ua~ !'-mOIOan,t' i

A.

DESCRIPTION OF WASTE

B.

HAND·

LING

METHOD

CODE

C.

DANGEROUS

WASTE NUMBER

(see instructions)

I

D.

We.t.

O••ign....

tlon

DWo,

EHW

E.

AMOUNT

OF

WASTE

I I I

I I !

I ! I

F.

..

::1&1 20

~8

I

I I I

I I

1

i " I I

i I' j

,

i i

! I

iii

I I

I ! I

i !

I I I

I I

I I

! !

I I i r--:--,- ------f--i--+---+,--+-,-t--t-f-+-+---i

I

i I

I I t I

I

!

i

i i

! ! I -_. r--oo,-oo- 00-------- _

i

I

!

I

,

!

j

9

8

3

I

I

14 !

I

15 I

11 i

tr

!

I--+---+---~I-------'- -------t--.,..---+--t--,-----;--.-+-;--;----r-+-.--t--i'-+--+-+--~_l___+__+___i

I

15. TRANSPORTER USED. (U.NMANIFESTED WASTE REPORT ONLY)

.-------------------------------------------------------4

16. COMMENTS

E<:Lee .S4,. fey 03().28 Reve,.. PAGc:.E OF _
PteeM priftC Of type .,", ELITE type f12 eMreet.,. per tftch).

SUteot TSD FACILITY ANNUAL DANGEROUS WASTE REPORTIUNMANIFESTED WASTE REPORT

Wolshington

Dep,artmenl : 1. Type of Dangerous Waste Report (check one) otEcoiogy ,

i 0 i .-.

! A. TSO FACILITY ANNUAL REPORT

• , . !

1

1

PLEASEPLACELABEL IN THISSPACE I

THIS REPORT FOR YEAR ENDING DEC. 31. lIT sO I UNMANIFESTEO WASTE REPORT

I !

FORM THIS REPORT IS FOR A WASTE

5 !

i RECEIVED ( month. day & year) I I ~I I ~11 19 / I

You may have received a preprinted label etteched to the front of this pamphlet. affix it in the designated space above. If any of the information on the label

ill incorrect. draw a line through .t and supply the correct information in the appropriate section belo..... If the label is complete and correct. leave Sections

2A, 3 and 41 below blank. However, be sure to complete Section 28. If you did not receive a preprinted label, complete all sections. "Facility" meana a

singlBllite where dangerous waste is transfered, trBaled, stored. or disposed.

!

2A. TSD FACILITY EPA/STATE 1.0. NUMBER , 2B. TSD FACILITY SIC CODE(S) !

I I I I I I r

I I I ! I ! !

I

• , I j

• i I I

I I I I

- I i i. I I I I I

3. NAME OF TSD FACILITY

I I I I I I , I I I I I i ! i I I I r

I ! !

! , I

I I

I I ! I i

I I

I r I 1

i I I i ! ! I , I 1 I

4. TSD FACILITY MAILING ADDRESS

Slr....I or P.O.Box

I II I I ri I I I i I I I I I ! I !I i

I I I

I j I I I I i I I II I , City or Town Stsle Zip Code

I I I I 1

i ! I

! I I I I ! I I I I r

! Ij I I

m ! i I I

! ! I I I I ! I I

5A. LOCATION OF TSD FACILITY I 5~CI C~~~%,~j WHICH TSD FA ILIT I: AT~O

SIreet or Route Numbs,

I I I I I ! I I I I I I I I I !·I I I I I I I ! I I I I I I I ,

Cily or Town SIsle Zip Cooe County

I I I I I I i i I ! 1 I I I I I I i

I I m r j ,

I I

,

! I I I I I I I I I I i I ! i

I I I i I I : ! I

6. TSD FACILITY CONTACT

Nams (I ..t snd fi,an Phone No. (sre8 code" numbs,)

I I I !

! I i i , , I i I i , I I

,

i : I I I I ! I I ; i i I

i i I ! I nil I ! I I ! !- I , ! ! I i I , ! I , i ! I- I I 1 I

7. COST ESTIMATES FOR TSD FACILITIES

A. COST ESTIMATE FOR FACILITY CLOSURE B. COST ESTIMATE FOR POST·CLOSURE MONITORING

(includes transfer, treatment. storage end disposal facilities) AND MAINTENANCE (disposal facilities only)

1$: ! ' I ! i I! 1

! i ! I

I I: ! !,i I I I !S I i i i ! ; I ! ! ; , ! , , , , , : i

", , I tf. I I

8. CERTIFICATION

I cenity under penalTy of //iw tnst ! neve persona;iy exsmined and am familiar with the information submitted in this snd a/l sl1ached documents. and that

bssed on my inqUlry·ot those indlvioullfs immediately resoonsiote tor obtsining tbe intormetion, I believe thsl the submitted information is true. accurate.

and complete. I em ewere that there ere significant penelties for submitting false intormetion, including the possibility of fine and imprisonment.

PRINTOR TYPENAME SIGNATURE DATESIGNED

ecv 03~12

ECLM ·64'. PAGE_'_OF _
-- :" r>;

TSD FACILITY ANNUAL REPORT/UNMANIFESTED WASTE REPORT

FORM 5

!CY 030012 INSTR.

1/82
~~.

....."' / FORMS

GENERAL INSTRUCTIONS FOR COMPLETING TSD FACILITY ANNUAL

DANGEROUS WASTE REPORT AND UNMANIFESTED WASTE REPORT

XIV. WASTE IOENnFICAT1ON ~, I U B. DANGEROUS C.HAHDI': A. DESCRIPTION OF WASTE WASTE LING

n. NUMBER MET1iOD D. AMOUNTOFWASTE ~~ .r (lee instructions (entercode) '" K 0'8'0 K 0'8'

S / 0/2 I I I /2/5/°1°1° T 1 Steel Finishing Sludge f--

2 Steel Finishing Sludge KOSO K 0 S 1 S 1°12 I I I 1

21 5

1°1°1° T

Impottant: Read an lnatructtona bef~ c0mpleting tllia form.

SeCtIon L TnMt of Dangeroua Waste Report

Faci1/ty ~I Report

F« ownera or operatora of on-alte or- off-alte

facllltiea lIlat treat, atore. or dispoae of

dangerous waste; fill in the reporting year tor

thIa report (e.g., la82).

lJIItMmt.ated Waat. Repor-t

For facility owneB or operatora who accept

for treatment, atorage. or diapoael any

dangeroua waste from an off-aite aource

without an accompanying manifeat; fill in the

data the waste was received et tha facility (e.g.

12-04-1982).

Section • ttlrv section tV. Inetallation 1.0.

Number, Nama of Inatallation, end Inatallation

MaUIng Addreae

II you received a preprinted label frOC'n EPA or

the Department of Ecology, atlach It In the

apaca provided and leave Sectione I through IV

blank. II there ia an arror or omission on the

label, croas out the incorrect informstion and fill

In the sppropriate Item(s). It you did not receive

a preprinted label, complete Section nthrough

Section IV.

Section V. Location of Installation

II your inatallation location eddreea ia different than the mailing addresa, enter the location addre.. of your inatallatlon.

Section VI. Installalion Contac1

Enter the name (last and firat) and telephone

number of the person who may be contac1ed

regarding information conlalned In thla report.

SectIon VI. Coat Eatimalea for TSO Facilities

A. Enter the moat recent coat eatlmale lor

lacillty cIoaure in dollars.

B. For dispoaal lacilities only. enter the moat

cost estimate lor Poat closure monitoring

and maintenance.

SectIon VlILcertification

The owner Of operatOf 01 the lacility or hia

allthorized repreaentative muat sign and date

the certification where indicated. The printed or

typed name 01 the peraon signing the report

muat alao be included where indicated.

Note.-Since more than one psge is required

lor each report, enter the page number of each

aMet in the lower right comer as w8l1 aa the

total number of pagea.

I!CY 0»12 INS11l.

EQ.F -273-

Facility Annual Report InatrucUona

Facility Annual Repor-t lOf owners or operators

of on-alte or off-site lacillties that treat, atore, or

dlspoae of hazardoua waste.

Note.-Generators who ship hazardous waste

off-site to a lacility they own or operate must

complete this form instead of the Generator Annual Report.

SecUon IX. Type of Report

Put an "X" in the appropriate box.

SecUon X. Facillty'a Identification Number

Enter the State/EPA identification number for

your facility.

s.c:tIon XI. Generator's Identification Number

Enter the State / EPA identilication number of

the generator 01 the waate deacribed under

Sec1ion XlV which waa received by your lacility

during the reporting year. A separate sheet

must be used lor each generator. It the waste

came Irom a foreign generator. enter the EPA

Identificetion number of the importer in this section and enter the name and addreaa 01 the

loreign generator in Section XV, Comments. If

the waste wss generated and treated, stored.

or diaposed of at the aame installation, leave

this section blank.

Example:

Section XIV-A. Description of Waste

For hazardoua wastea that are Iiated under

WAC 173-303. enter the Iiated name, abbreviated if necesaary. Where mixtures 01 listed

waates were received, enter the description

which you believe best deacribea the waate.

For unlisted dangerous wastes, enter the

description which you believe best describea

the waste. Include the apecific manufacturing or

other process generating the waate (e.g., green

sludge from widget msnulacturing) and if known.

the chemical or generic chemical name 01 the

waata.

s.c:tIon XII. Generator's Name

Enter the name 01 the generator corresponding to the generator'a State/EPA identification

number In Section XI.

It the waate came from a lorelgn generator-,

enter the name 01 the importer correapondlng to

the EPA identification number In Section XI.

s.c:Uon XIII. Generator-'a Addre ..

Enter the addre8ll 01 the generator- correspon'

ding to the generator'a State/EPA Identlllcation

number in Sec1ion XII. It the waate waa

generated and treated, atored, or diaposed 01

at the aame installation, leave this aection

blank. If the waste came from a Ior-8Ign

generator, enter the addess 01 the Importer cor--

responding to the EPA identilication number in

Sec1ion XII.

s.c:Uon XlV. Waste Identification

All inlormation in this aection must be entered

by line number. A separate line entry la required

lor each different waste Of mixture of wastea

that your lacility received during the reponing

year. The handling code spplicable to that

waste at the end 01 the reporting year should

be reported. II a dillerent handling code appliea

to portions 01 the same waste, (e.g., part of the

waste ia storod while the remainder waa

"chemically fixed" dUring the year), use a

separate line entry lor each portion.

SecUon XIV-B. Dangeroua Waate Number

For Iiated waste. enter the lour digit

Dangerous Wsste Number WAC 173-303 which

identilies the waste.

For a mixture of more than one liated waate,

enter each of the applicable Dangeroua Waste

Numbers.

Four spaces are provided. If more apace is

needed. continue on the next line(a) and leave

all other inlormation on that line blank.

·278·
............, l~ _. -oj

SUteoi TSD FACIUTY ANNUAL DANGEROUS WASTE REPORTIUNMANIFESTED WASTE REPORT

w....on

I. Type of Dangerous Waste Report

8 01 FACIUTY ANNUAL REPORT

THIS REPORT FOR YEAR ENDING DEC. 3t, /11 91 I

PLEASE PLACE LASEL INTHIS SPACE

.- 01 UNMANIFESTED WASTE REPORT

FORM THIS REPORT IS FOR A WASTE

5 RECEIVED ( month, day & year) I I I H1191 I

INSTRUCTIONS: You may have received a preprinted label at1ached to the front of this pamphlet; affix it in the designated space above. " any of the

information on the label is incorrect, draw a line through it and supply the correct information in the appropriate section below. If the label is complete and

correct. leave Sections II. III. and IV below blank. If you did not receive a preprinted Isbel. complete sll sections. "Facility" means a single aite where

dangerous waste is generated, treated. stored, or disposed of.

II. FACILITY STATE/EPA 1.0. NUMBER

I I I I I I I I I I I I I I I

'1

III. NAME OF FACILITY

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

IV. FACILITY MAILING ADDRESS

StreetorP.O. Box

I I I I I I I I I I I I I I I I I I I I I I I I I I I I

CityorTown Stete ZipCode

I I I I I I I I I 1 I I I I I I I I I I I I I / I I I I I

V. LOCATION OF FACILITY

StreetorRoute Number

I I I I I I I I I I I I I I I I I I I I I I II I I I I

CltyorTown State ZipCode

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

VI. FACILITY CONTACT

Name (Ieetand firat) Phone No.(areacode& number)

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I-I I I 1- I I- I I

VII. COST ESTIMATES FOR FACILITIES

A. COST ESTIMATE FOR FACILITY CLOSURE B. COST ESTIMATE FOR POST CLOSURE MONITORING

AND MAINTENANCE (disposal facilities only)

lsi I I II I I II I I I sl I I I I I I I I I I

XIII. CERTIFICATION

I certify under penalty of law that I have personally examined and am familiar with the information submiNed in this and all attached documents. and that

based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true. accurate.

and complete. lam aware that there are significant penalties for submiNing 'alse information. Including the possibility of fine and imprisonment.

-

A. PRINTORTYPENAME B. SIGNATURE C. DATE SIGNED

lEey 0»-12
.~

;;1 ....::-~~ !

FACILITY ANNUAL REPORTIUNMANIFESTED 'WASTE REPORT

1. OA~

FOR OFFICIAL I II I II I I I I IX. TYPE OF REPORT (Enter 8ft "X") X. FACtUTY'S STATE/EPA I.D. NO.

USE ONLY 2. REVIEWED BY o FACILITY o UNMANIFESTED

.1 I I I I I I I I I I I (ITEMS 1 AND 2) ANNUAL WASTE

REPORT REPORT

XL GENERATOR'S IDENTIFICATION NUMBER XUI. GENERATOR ADDRESS (STREET OR P.O. BOX, CITY, STATE .. ZIP CODE)

I I I I I I I I I I I I

XII. GENERATOR NAME (apeclfy)

XIV. WASTE IDENTlFlCATION

C. I lE·w'i B. DANGEROUS HAND- D. AMOUNT LII ~a:"8 WASTE NUMBER UNG OF ~u

I • A. DESCRIPTION OF WASTE !:~.! :: METHOD WASTE (see instructions) enter code) ! zw c ~~.!

,

1

2

3

4

5 ,

6 ,

7

8

8

10

11

12 :

I

XV. COMMENTS (ENTER INFORMATION BY LINE NUMBER SEE-INSTRUCTIONS)

-