# 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 2ECl.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)

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### of FACILITY 1.0. NUMBER 

### Wuhington Dep.utment 

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# , Icertifyunderpenaltyoflawthat Ihavepersonallyexaminedandam familiar with the information submittedin this andall attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, Ibelieve that the submittedinformation is true, accurate, andcomplete. Iam aware that there are significant penalties forsubmittingfalse information, inclUding thepossibilityoffine andimprisonment.
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


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# 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 

# Attn: 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

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## mailing address) 

## Be sure to enter the 

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## FACILITY CONTACT E) \)WNERSHIP 

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# kcd G) CERTIFICAnON transporation 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 

## Actual 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)

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## Stateot Wuhlngton Oepmmenl 

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# MS-PV-Il Olympia, 

# WA 985C 4 

# FORM 2 

# NOTIFICATION OF DANGEROUS WASTE ACTIVITIES FACILITY 1.0. NUMBER 

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## G, CERTIFICATION _.- 

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## ---------- 'certifyunderpenaltyoflaw that Ihavepersonallyexaminedandam familiar with the information submittedin this andett attached documents, and that baaed on my inquiry of those individuals immediately responsible for obtaining the information, Ibelieve that the submittedinformation is 

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SIONATURE

fCY 030-5

ECLA -280- 

### ! NAME & OFFICIAL TITLE (tvpe or print)

(COMPLETE REVERSE) DArE SIGNED

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# 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 PROCEDURESI

...**?"'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<sunless 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 locoled 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 srea odondlng 8t leoAt 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 insertron 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 conatructedj. leave Ihis itern blunk.

section IV Give the complete mailing address 01 the office where correapondance 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., prooucts 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-

# JFORM 

# 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 D. ZIP CODE C.STATE B. PHONE (area code & no.) i I 

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i I I A. STREET OR P.O. BOX 

# H


# " V. FACILITY LOCATION A. STREET. ROUTE NO. OR OTHER SPECIFIC IDENTIFIER 

# I 

# H -'---'-_-"..
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# --------·-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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### --t

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## IV. SIC CODES (4-digit, in order ofpriority) A. FIRST

E. STREET OR P.O. BOX I I I
F. CITY OR TOWN 1 1 G.STATE 

# i

# I 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 underpenalty '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 oftnose persons immediately responsible for obtaining the information contained in the application, t believe that the information is true, accurate and complete. tam aware that there are significant penalties for submitting false information, including thepossibilityoffine andimprisonment. B. SIGNA TURE A. NAME &OFFICIAL TITLE (type 0, p"nt) 

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



### ECY030-31 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 topurchase or 

### contrects forfeasibility, 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 whetherthe 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 changesare requested. tnaddition, Items landIX(andItem X if applicable]mustbe completed. It is not necessary to resubmit information forotheritems thatwiltnotchange).**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 storagearea, 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 eithera principal executive officeror ranking elected Official. 

# C')**'~~-!-".:.-'**



# . "

# ~'t1aI:Mprau Of type 1tI I". unanaau .retlaoruy (tm-it1 ,_,,,. apacedloreltl. /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 

# r 

# I , ! 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 Ieyour tlral application and you already knowyour facllity'a EPA I STATE I.D. Number. or if 'hla la a revlaed application. enteryour facility'a EPA I STATE I.D. Number In Section Iabove. 

## T fiRST-APpLICATION 

## (plsce**an~** 

## ..x .."below

## 5ric{prtiviiiethespp;·oprlstiidate)
- 

# 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 ,--- FOREXISTING FACILITIES. PROVIDE THEDATE (mo. aev. &yr) OPERATION BEGANOR1liE DATE CONSTRUCTION COMMENCED (use the boxes to the left) 

# Q 2. NEW FACILITY (Complete item below.) FORNEWFAClUTIES. PROVIDE 1liEDATE (mo

.. day, & yr.)OPERAnON BEGAN OR IS . EXPECTEDTOBEGIN B. REVISED APPlICAnON (place an "X"belowand comptete Sec/Ion Iabove) 

# 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 belowthat 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 enterthe capacity 01 the precess. 1. AMOUNT - Enter the amount. 

### 2. UNIT OF MEASURE - For each

### smountentered in column B( 1), enterthe code from the list of unit measure codes belowthat deacribes the unit of measure uaed. Only the unlta of

measurethat 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

UNITOFMEASURE 

# ..**-::£~';1** .Storage: CONTAINER (barrel, drum. erc.) TANK WASTE PILE**SURFACEIMPOUNDME~T** 

### DlaPOH': INJECTION WELL LANDFILL
LAND APPLICATION OCEAN DISPOSAL SURFACE IMPOUNDMENT
UNITOFMEASURE 

### 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 ORHECTARES GALLONS PER DAY OR LITERS PER DAY GALLONS OR LITERS
UN'T OFMEASURE 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

. CUBICYARDS

. CUBICMETERS

.. GALLONS PERDAY G

... L

....... Y

. C .. U LITERS PERDAY

. TONSPERHOUR METRICTONS PERHOUR

. GALLONS PERHOUR

.. LITERS PERHOUR

.. 

### .. .. v D 

### 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
I

# 5 

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## 20 600 

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## 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 densityor specilicgravity 01the waate. D, PROCESSES 1. PROCESS CODES: ForlIated dangeroua waate: For each lIated dangerous waste entered in column Aselect 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 10indicate all the processes that will bo used to store. treat. and lordispose of all the non-listed dangerous waate. 'hot posseaathatcharacteristicor toxic contaminant. Note: Four spaces are provided for antering procesa codes. If more are needed: (1) Enterthe 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 inthe 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, andX-4 below)
- Afscility 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 notenreredinO(OJ I

# i D. PROCESSES



### I
I I
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# T 0 3 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' (6ntercode) 

### 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· 

### ECY0»31 Form 3 PAGE 

### 2 OF 5 CONTINUE ON PAGE 

### 3

### Continued trpm page 2.

. NOTE' Photocopythispagebefore completing if youhave mora than26 wastas tolist 

# I 1.0.NUMBER(anter from

### paga I) 

# I I ! 

# I I I I I
DESCRIPTION OF DANGEROUS WASTES (continued) 

# r;

# ------------1---------------------------------------4**'~IV.**


### 2. PROCESS DESCRIPTION (ifa code IS nol entsredinOf') 

### O. PROCESSES



## ._-,-------_._--------------_._------_._-- 1. PROCESS CODES (enter) 

### B. ESTIMATED ANNUAL QUANTITY OF WASTE



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ECl30 ·271·**ECY~31** 

### Fonn3 

### PAGE 3_0F 5 (enter "A", "S". 

### Ole" etc. behind the "3" to identifyphotocopitldpsass) 

### CONTINUEON REVERSEI 

# 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 

## VI1I. FACILITY OWNER I I 

# 0 

# I A. If the facility owneris alsothe 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. lithefacility owner ia not the facili.y operatoras 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 possibilityoffine andimprisonment.**~---'-** 

# ------ NAME (printor 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 possibilityoffine andimprisonment. NAME (prlnfortype) SIGNATURE DATE SIGNED

ECL3E ·27'· 

### ECY030-3tForm3 

## PAGE 4 OF 5 CONTINUE ON PAGE 5Continued 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. :'::0OO( 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 routa 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 producta 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:·. fe<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

### a5;-**!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(Enterthe appropriateletterinto the answerbox; if "Other", soecitv.) 

### D. PHONE(ar8a code & 

### no.) F -FEDERAl M m 

### PUBLIC (otherthan federalorstate) 

# ! I (specify) 

# I I 

# II I I 

# II I S - STATE 

# o OTHER(apecify) 

# r---------i P - PRIVATE 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 underpenalty of 

## iaw that I have personally examined and am 

## familiar with the information submitted in this application and all at

# tecnmems and that.**bas~d** 

## on :ny 

## inquiry of those persons immeaietetv responsible for obtaining ;he information containedin the application, I believe that the intormetion IS 

## true. eccurste and complete. / am 

## aware that there are significantpenalties for submitting false information, including the possibitityoftuie andimprisonment. 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.es 

## ,"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'~'';** '."", 

### forthe facility ptace an"X" 

### in srrnerthe 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, approvers ); 

### 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 -s

### sue 

### construcu-z-: program). or (2·b) The owner or operator had entered into 

### contractuaobligations (options to purchase or contraCIS 

### fortees.cu.r. engineertng. afld design studies do il0t 

### coast.ti.se ;.;. trectuet obligations) which could not be 

### canceuec ;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: -: 

## es 

## are a 

### '3·: .:.**.e~** 

### ";r t;C· 

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

### t980. NEW FAClli

### Tv 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 arerequesfed. Inaddition, /lems IandIX(andItem X ifap· pllcab/e} must

### be completed. /I is n"tnecessary to resubmit information forotheritems that 

### will notchange). ECV030-311NSTR. 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 

### orccess must be provided as part of the .ies

### cr.ct.oo.**~r,e** 

### de

### s.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 cescnoes 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 

### esurna t

### ec**F'l~a,** ":;',3":';'{ 

### vi**')a:~'** 

### ..asre must be provided. See 'l"d ° ';rrt**'~r :'r'~**  

### ·1eta:le.:**i!S~(uct!crs.·o** 

### Section 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 incmer

### s: :« Jr'.111 

### storage area, etc.); Areas 0:1 

### csst 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

..;; structures: all e/(isting areas lor storing, treating, or**dispos'~g** .:;f 

## nazardous 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 facilitywill 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 officeror ranking elected official.

# ..._,.., , It. ""0".1010;11101 a. vao VIII'



### PAGE 1 OF 6 !CY 030-31 Form 3 _. ._. _ ........ .u......- ••

_ ......- 

### Cl3B**.~** (m/-in .r ...• ,.apecedlex

# ./JI. type i.« 12ch.r.ct.raIinch) , 

### . 

# .. 

# -

. . 

## I. EPA/STATE J.D. NUMBER FORM 

# 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 ; P18cean 

### "X" In the appropriate box In A or B below (markone box only) to indicate whetherthia ia the firat application you are submitting for your facility or a revlaed application. "this I. your flrat application and you alreadyknow your facility's EPA/STATE 1.0.Numbar, or if thia Ie a reviaed application, enteryour faclllty'a EPA/STATE 1.0. Number 

### In Section I.bove. A.**~ST** APPLiCAnON (place an .. 

# x..belowand 

### provide the appropriatedBfe) 

# 0 1. EXISTING FACILITY (S••ln.,ructlon.'ord.finlt/on ol

....ialing

..

### tscuttv. 

# Q 2. NEWFACILITY (Comp/el.llembel_.) Compl.t. it.m b.lo

...) FORNEWFAClUT1ES. PROVIDE 

### ntEDATE

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

# --T-i~~ (mo., day. &yrJOPERA. OPERATION BEGANORTHE DATE CONSTRUCTION COMMENCED TlONBEGANORIS (ua. thebo••a to Ih.,.ft) 

# ---l..-...j EXPECTEDTOBEGIN 8. 

### REVISED APPLICAnON 

### (plBcesn ..

# x..below 

### BndcompleteSection Iabove) 

# o 1. FACILITY HAS AN INTERIM STATUS PERMIT 

# o 2. FACILITYHASAFINALPERMIT 

## III. PROCESSES 

# - CODES AND DESIGN CAPACITIES
A. CODE - Enterthe codefrom the list of process codea belowthat 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).


# .. PROCEllD!SlGN CAPACITY - For sach code entered in column A entarthe capacityof the process. 

### 1. AMOUNT
- Enterthe amount. 2. UNIT OF MEASURE - For each amount antered in column B( 1

# >, enterths code from the lIat of unit measurecodes balowthat dascribeathe unit of measure used. 

### Only

### theuntil01 meaaurathat are IIstad below should be used. PRO- APPROPRIATTEUNITSOF PRO- 

### APPROPRIATTl! 

### UIIIT8OF CESS MEASURE FORPROCESS CESS IIl!ASURI! FORPROCI!88 PROCESS CODE DESIGNCAPACITY 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 GALLONSOR LITERS INCINERATOR T03 TONS PER HOUR 

### OR METRIC TONS PER 

### HOUR; DIapoNI: GALLONS PER HOUR 

## OR INJECTlONWEU 079 GALLONSOR LITERS LITERS PER HOUR 

### LANDFIU. 080 ACR1.·FEET (the volum. thaI OTHER (Use for physical, chemical, waul 

### coverone

### ecre to B thennal or biological treatment T04 GALLONS PER DAY

### OR depth 01 on. 1001) LITERS PER DAY ORHECTARE·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 

### UNITOFIlllU8URE CODE UNITOFMEASURE CODE UNITOFMEASURE 

### CODe OAU.ONS

................... 

### ....... ..... . G LITERS PERDAY

... 

### . . .

## . . 

### . ..... 

## .... 

## ........ .. ... V ACRE·FEET

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

### UTER8
............... L TONS PER HOUR

.... . 

### .... . . . . . . . . . . ........ ..... 0 

### . ...... 

## .. , 

### . . .

## .. . ........... ...... ....... . ........ HECTARE·METER

.. . ..................... F CUlllCYARDS

........... Y METRIC TONS PERHOUR ., 

### ...... ........ W 

### .

## ...... ... ... ,. 

### ....... ACRES

. ..................... B CUlllCMETERS

............. C GALLONS PERHOUR

. ...... E 

## ........... .......
.......... ..... 

## ... .. , 

### ...... .... ...... 

## ... HECTARES

.......... ........................ Q GAU.ONSPERDAY

...... ... 

## .... ........ ..... .U LITERS PERHOUR ., .. , 

### .... ....... .. ......... 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. UNITOF MEASURE
- For each quantity entered in column B enterthe 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 IIlactlltyracords use any otherunit of measure for quantity, the units of measure must be converted into one of the required units 01 measure laking into eccount the appropriate

### denaltyorapeciflc grevityof the waste. 

### D. PROCESSES 1. PROCESS CODES: ForlIated dangeroua waste: For each listed dsngerous wasle entered in column Aselect the ccdeta) from the list of process codes contained in Section III to btdloate

### how the wastewill be stored, treeted, snd lordisposed 01 at the facility. Fornon-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 numberand 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, andX·4 below)
- Afacility will treat and disoose of an eatimeted 900 pounds per year01 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 Willbe an estimated 100 counos per year of that waste. Treatment 

### willbe in an Incbteratorand disposal will be in a landlill. 

## i 

## - L A. 

# I C.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) (ifB coae a notenteredin DC rJ) 

## 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 0Continued from pege 2.



### NOTfil 

### PIIolOCOf!Iythillpagebefore completingif you hevemore 

### msn26 

### westes to list 1.0.NUMBER 

### (enterfrompllge 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 life code " no, enfModin 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 

# ! ; 

# i 15 

# 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 , 

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### I i I 

### I 

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# 18 , ; 

## , I I 

# I J 

# : I I 

## i 

# I 

# ! 19 I 

# {- 

# HI I I I ! 

# I I I I 

### I 

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# 20 , I 

# . i I I, 

# I I I : I I I 

# 21 I I 

# , I I 

# I 

# ! I 

### I 

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### I I 

### I I 

# , 22 I I 

### I I 

## I 

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## , 

# , I 

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# 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**~OF** 

### 5-----
..----..---·····-' ·_·_·

__·•·•••..•·

__·'-·_

.. CONT1NUEONREVERSE

### i (enler "A", "S", "C" elc. behindIhe "3" 

### to identftyphotocopied**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 alsothe facility operatoras listed in Section 

### VII on Form 

### r. "Generallnformalion", place 

### an "X" in ths box to the Isl1 and skip to Section 

### IXbelow.


### B. 

### Itthe facility owneris 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 underpenalty 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 thepossibilityoffine andimprisonment.**NA~E** (prlnfortype)



## X. OPERATOR CERTIFICATION SIGNATURE 

### 1 DATE SIGNED 

### I 

# I I

I certify underpenalty 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 possibilityoffine andimprisonment. NMtE (prlnl ortype) 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 Cudtt WEIGHl CODE

... 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! OrgeneflC chemrcat 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 atate . 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 more 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 8Sdelermined underWAC 173·303·070through**173·030·10~.** Enler the 

### cor responding code OW·-Dangarou8 Waete EHW-EKtramely Hazardous Waste Section 140. Amounl 

### 01 Waste.

Enterthelolal amount or this walle (by weighI) you ehlpped to Ihe TSOlecdity ,denillied InSecnon I' duro 

### 'ng Ihle ,eportlng year.

Unite 01volume 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). plealie 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 firat) 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 

### otthe pereon signing the report must also be inctuded where indicated. Seclion 

### 8. Certlllcatlon.

Section 10. TSD Facility's EPA/STATE Identification Number Enler Ihe EPAtStela Identilicatlon number ollhe TSD lacllilyto 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. Aaeparate 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

Enlerthe addresa 01 the lacillty corresponding to the TSD lec,lIty'a EPA/State Idenlilication number in Sec· lion 10. Section 11. TSD Facility Name.

Enterthe name of Ihe faclUty corresponding 10the TSOlaclllly'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 lalerthen 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 apreprln'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. IIyou 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 SICcode which beal deacribea your buaine

.. activillea. Uae Ihe U.S. Dep't. of Commerce "Slandard Indualrlal Claaailication Manual." IImora Ihan ona SIC COdela applicable 10your actlvltiea, li.t all SICcode. which ba.t de.cribeyour 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 anotherTSO '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 10anothor TSO tat.:illty (whether owned foperated by your••U or ."o.he, perlon), you muat completeboth Forme 4 and es. IV) If you own Oroperate a TSO lacillty only and ALL OW tEHW are managed on-aUe, you muat complete Form II only. NOTE: In'on"8110n required Ineny 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 letterwhich 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. enterthe locetlon address of your Inalellatlon. Section 13. Transporter(a) Used List Ihe name end EPA ..Stile identification number of Ihe "anaporter(8) used 10transport wastnll 10 lhe TSO facility named In Section 11**SQc~lon** 15. Commanls. Thl8 space may be used 10e",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 Chemlcel

# I

State Nature I 14.
L M I U

II 

## 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 

# I

# iI

# dtit 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 InWhich Generator Is Located



## 6. GENERATOR/CONTACT Nema (losl ftnd llrat) Phone No (ltrtt8 code &number) 

# :! r 

# i , -- - T 

# r ....:- "-[T-;'rI 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 

# --_.--_..**_-_._---------.------------_._-----------------------------~**



### Icfulifyunderpensltyof Isw tnet I 

### hsvepersonslty exemmea snd

### sm familiar with the information submittedin this and al/sttscheddocuments. sndthst bssedon 

### myinquiry of those mdividusls immedistely re.sponsible for obtsining the intormetion, fbelieve tne: the submittedintormstion is 

### true, sccurste. sndcomplete. Ism swsre thst there sre significsntoeoenie« for submitting tetse iotormetion, including the possibilityoffine sndimprisonment.

ECl.O**~.I** PRINT OR TYPE NAME
fey 030-ze SIGNATURE DATE SIGNED



### PAGE OF

# ...--... -,

II. GENERATOR'S EPA'STATE IDENTIFICATION NUMBER 

# GENERATOR FORM 4

'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. 1M 

## Me 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 I

___L

_ 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

# f5**lOJ ""**  I :::.... 'U '-' ..:::J

# 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.1m3 "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. 

### Ifmore fhan !"ur spaces are' required. 'oucw the crocsours**:~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 cor**renpon~ing** 10 the fACility's EPA/Stale identifica· tion number in Section X.**~nl~f** 1119 118mB of !tie !eClnty correspondinq 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. Saclion 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 firat) 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 toeation 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 dangerouswaste is generated. treated. stored. or disposed.


## II. FACILITY EPA/STATE 1.0. NUMBER
III. NAME OF FACILITY
IV. FACILITY MAILING ADDRESS Street orP.O. 

### Box



## V. LOCATION OF FACILITY

VI. FACILITY CONTACT



# 1----------------------------------:------------------------1

VIII. CERTIFICATION Icertifyunderpenaltyoflaw that Ihavepersonallyexaminedandam 

### familiar with the information submittedin this andallattacheddocuments. andthat baaed

### on my inquiry ofthose individuals immediatelyresponsible for obtaining the information. Ibelieve that the submittedinformation is true. 

### accurate, andcomplete. lam aware thatthere are significantpenalties for submitting false information. including the possibilityoffine andimprisonment.

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 (ENTERCOOE)


### 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 1
...lnorganic**(s~e** 

### instructions) 

# ! R S-Sludge 

# . 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 

## ! 

# I 13 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) (entercode) Important: Reed all inatructlons betore completing this form. 

## GENERAL INFORMATION 8ectlon I_ Type of Dangeroua Waate Report



### FacilityAnnual 

### 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, enterthe dangerous waste numbers applicable to the waste. If morethan 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 Code Unite of Mea8ure 

## (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 T

### 48 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.Pleaept1n1Of

### l7Pe wfth ELITE type (12 ehareel

... perInch). 

### . 

## --,



## sc.teof 

# TSD FACILITY ANNUAL DANGEROUS WASTE REPORTIUNMANIFESTED WASTE REPORT Washington Departmenl 

# I I. Type of DangerousWaste 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 dangerouswaste 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 StreetorP.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 ; CityorTown 

# 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 

## .-

.. 

### CityorTown 

# 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) 

# r1 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 ! , 

## ! 

# T 1 

# 1 j 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 Icertifyunderpensltyottsw thstIhev»personallyexaminedand sm familiar with the informstion submittedin this and sllettecnea documents, sndthst 

### bssed on myinquiryofthose individuals immediately responsible for obtaining the information, Ibelieve that the submittedinformation is true, sccurste, sndcomplete. I amaware that 

### there are significsntpenalties forsubmitting false information, including the possibilityoffine andimprisonment.



### PRINTORTYPE NAME SIGNATURE DATE SIGNED 

## eey0»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--

# -+-++.1

1 :

# -~ 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 Oroperate.



### 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



### LIatthe 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 

# ... W"'STE

# ~~ .... DESCRlPTlON OF W"'STE NUMBER 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 MeaaureEnter 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 fil

### ed. Important: 

### Reed All lnetructlona Before 

### C0mpleting 

### ThIs Form



### The Unmanlfeated Waate report muat 

### be filled 

### out according to the directiona for the Facftlty An

### nual Report except that: (1) blocka for which in

### formation 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 T

### 40 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, drawa 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 hazardouswaste 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

### underpenalty 

### oflaw that I have personallyexaminedandam 

### familiarwith the information submittedin this andall 

### attacheddocuments. and that
I 

### based onmy 

### Inquiryofthose individuals immediatelyresponsible forobtaining the information, , believe 

### thatthe submittedinformation is true. accurate• • ndcomplete. Iam 

### aware that there are signlficanfpenalties 

### forsubmittingfalseInformation, Including thepossibilityoffine and imprisonmenl.



# ..



# -- A. 

### PRINTORTYPENAME 

### B. SIGNATURE C. DATE8lONED

# 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 

# I i 1 

## 2 

## 3 I I 

# i I 

# i 4 

# I I 

# I
I 

## ! 

# ! 5 I 

## 6 

## 7 

## 8



# .. I 10 

## 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 CompletedForms 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 lorT.S.D. l.cUltie. by Me,ch 1 01the 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. 01 Ih. 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 10rele.ae inform.tion contalneo in • confioenli.1 ,eport, Ihe d.pertment

...ill noIltyyou. 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

Foro...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 Inthe 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 Section 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 report109 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

# !Jio 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 

# 1 s·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,.lorOwninll or operalino your 0- T80 tacility anoyou man.ge ALL OW/EW,",**~e,ated** by you or Olhe'. on·.lle. you mu.t com· plete Fo,m 5 onty. UI) IIyou .re • gener.to, who o...n. or oper.'e. your

## ownTSO 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) IIyou 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, ordiepoael any (I.noeroue w••'. 

### from .noU·.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 

### SICcod

....hlch be. I lle.c,lbe. your bu.ine

.. actlvlllea. U

.. the U.S. Oep't, of COntmerce "SI.ndarll lnduat,

..1Cle.allicalion Manual". IImoreth.n ona SIC code 

### I. applicable 10yoUf aClIY"laa, lIal alt 

### SICcode. 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 onlythe 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 Tt2 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 Surtsce 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 t73·303·104. Enterthe 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 

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# I

15. TRANSPORTER USED. (U.NMANIFESTED WASTE REPORT ONLY)



# .-------------------------------------------------------4 16. COMMENTS



### E<:Lee 

## .S4,. fey 

### 03().28 Reve,
.. 

### PAGc:.E OF _PteeM priftCOf type .,", ELITE typef12 eMreet.,. pertftch). 

### 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

# lIT I THIS REPORT FOR YEAR ENDING DEC. 31. PLEASEPLACELABEL IN THISSPACE 

# sO I 

### UNMANIFESTEO WASTE REPORT 

# I ! 

## FORM THIS REPORT 

### IS FOR A WASTE



# 5 ! 

# i RECEIVED ( month. day 

### & year)

# I 

# I**~I** I

# ~11 1

## 9 / 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 

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# I I ! 

# I ! ! 

# I

# •

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# • i I I 

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# 3. NAME OF TSD FACILITY 

# I I I I I I 

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# I 

# i ! 

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# I i 

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### I 

# 4. TSD FACILITY MAILING ADDRESS Slr

....I or P.O.Box 

# I II I I r 

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# I 

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# i I I 

# I 

# I I 

# ! I ! 

# I i 

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# I I II I I I I 

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# I I I 

# I r 

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# ! 

# I 5A. LOCATION OF TSD FACILITY 

# I**5~CI C~~~%,~j**  WHICHTSD FA 

## ILIT I:**AT~O** SIreet or Route Numbs, 

# I I I I I ! 

# I I 

# I I I I I 

# I I 

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# I I I I I I 

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# , Cily or Town SIsle Zip 

### Cooe County 

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# I 6. TSD FACILITY CONTACT Nams (I

..t 

### snd fi,an 

### Phone No. (sre8 code" numbs,) 

# I I I ! 

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# i i 

## , 

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## ! I i I 

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## , 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 

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## 8. CERTIFICATION I

### cenity underpenalTy of//iw 

### tnst ! 

### neve persona;iy exsminedandam 

### familiar with the information submitted in 

### this snda/lsl1acheddocuments. and that bssedon my 

### inqUlry·ot those indlvioullfs immediately resoonsiote tor obtsining tbe intormetion, I believe thsl the submittedinformation is true. accurate. andcomplete. Iem 

### ewere that there ere significantpenelties forsubmitting false intormetion, including thepossibilityof fine andimprisonment.

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.HAHD

# I': A. DESCRIPTION OF WASTE WASTE LING D. AMOUNTOFWASTE

# ~~ 

# n. NUMBER MET1iOD 

# '" 

# .r (leeinstructions 

### (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

# 2151°1°1° T 

## Impottant: Read 

## an lnatructtona**bef~** c0m

### pleting 

### 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 thIareport (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 dif

### ferent than 

### the mailing addresa, enter the location addre

.. of your inatallatlon. Section 

### VI. Installalion Contac1 Enter 

### the name (last and firat) and telephone 

### numberof 

### 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 

## comeras w8l1 

## aa the total 

### numberof 

### 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. Typeof DangerousWaste Report 

# 8 01 FACIUTY ANNUAL REPORT THIS REPORT FOR YEAR ENDING DEC. 3t, 

# /1191 I PLEASE PLACE 

### LASELINTHIS 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, ordisposed 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 StreetorRouteNumber

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. FACILITYCONTACT Name(Ieetandfirat) PhoneNo.(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 Icertifyunderpenaltyoflaw that I havepersonallyexaminedand

### am familiarwith the information 

### submiNed in this and all attached

### documents. and that 

### basedon

### my inquiry of

### those individuals 

### immediately responsible forobtaining the information, 

### I believe thatthe submittedinformation 

### is true. accurate. andcomplete. lam

### aware that there 

### are significant

### penalties forsubmiNing 

### 'alse information. Including thepossibilityof

### fine and imprisonment.



# -

A. 

### PRINTORTYPENAME 

### B. SIGNATURE C. DATESIGNED 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

## ~a:"8 LII WASTE NUMBER UNG 

### OF**~u** 

### I • A. DESCRIPTION OF WASTE

### !:~.! 

# :: METHOD 

### WASTE 

### (see instructions) entercode)

# ! zw c**~~.!** 

## , 1 

## 2 3 4 

## 5
, 6 

## ,
7 

## 8 

## 8 10 11 12 

## :
I 

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



# -