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ECY030-31 Instr. (Rev. 7/97)

Part A

Dangerous Waste Permit Forms

(Forms 1 and 3)
Washington State

Dangerous Waste Permit

General Information c

Permit Application Process

There are two parts to a Dangerous Waste Permit

Application-Part A and Part B.

.:. Part A consists of Form 1 and Form 3.

.:. Part B requires detailed site-specific information

such as geologic, hydrologic, and engineering data.

WAC 173-303-800 specifies the information that will

be required from dangerous waste management

facilities in Part B.

Operation During Interim Status

Part A of the permit application defuies the processes

to be used for treatment, storage, and disposal of

dangerous wastes; the design capacity of such

'processes: and the specific dangerous wastes to be

handled at a facility during the interim status period.

Once Part A is submitted to the Department of

Ecology, changes in the dangerous wastes handled,

changes in design capacities, changes in processes, and

changes in ownership or operational control at a

facility during the interim status period may only be

made in accordance with the procedures in WAC

173-303-820. Changes in quantity of waste handled at a

facility during interim status can be made without

submitting a revised Part A provided the quantity does

not exceed the design capacities of the processes

specified in Part A of the permit application. Failure to

furnish all information required to process a permit

application is grounds for termination of an interim

status permit.

Confidential Information

All information submitted in this form will be subject

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 CRF Part 2 (seeespeciaDy40 CPR2.305),and will be

subject to the State of Washington Public Records Act

chapter 42.17 RCW and chapter 43.21A-160 RCW.

Persons filing this form may make claims of

confidentiality. Such claims must be clearly indicated by

marking "confidential" on the specific information on the

form for which confidential treatment is requested or on

any attachments, and must be accompanied, at the time

of filing, by a written substantiation of the claim, by

answering the following questions;

ECY 030-31 Insrr, (Rev. 7/97)

Confidential Information (continued)

A. Which portions of the information do you claim

are entitled to confidential treatment?

B. For how long is confidential treatment desired for

this information?

C. What measures have you taken to guard against

undesired disclosure of the information to 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 state agency made a pertinent confidentiality determination? Ifso, what would those

harmful effects be and why should they be viewed

as substantial? Explain the casual relationship

between disclosure and the harmful effects.

If no claim of confidentiality or no substantiation

accompanies the information when it is submitted,

EPA or the department may make the information

available to the public without further notice to the

submitter.

Definitions

Terms used in these instructions and in this form are

defined in the Definitions section of the Dangerous

Waste Regulation, chapter 173-303WAC.

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Form 1 - Instructions

• This form must be completed by all applicants.

•

•

Completing This Form

Please type or print. If you print, place each character

between the marks. Abbreviate if necessary to stay

within the 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

Space is provided at the upper right-hand comer of

Form 1 for insertion of your EPA/State identification

number. If you have an existing facility, enter your

identification number. If you don't have an EPA/

State identification number, please contact the

Department of Ecology (360) 407-6000and one will be

provided for you. If your facility is new (not yet

constructed), leave this item blank.

Section II

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

colloquial name.

Section III

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 and who can be contacted if necessary.

SectionN

Give the complete mailing address of the office where

correspondence should be sent. This often is not the

address used to designate the location of the facility or

activity.

Section V

Give the address or location of the facility identified in

Section III of this form. If the facility lacks a street

name or route number, give the most accurate

alternative geographic information (e.g., section

number or quarter section number from county records

or at intersection of Rts. 425 and 22).

Section VI

List, in descending order of significance, the four

4-digit standard industrial classification (SIC) codes

which best describe your facility in terms of the

principal products or services you produce or provide.

Also, specify each classification in words.

ECY 030-31 Instr, (Rev. 7/97)

These classifications may differ from the SIC codes

describing the operation generating the dangerous

wastes.

SIC code numbers are descriptions which may be

found in the "Standard Industrial Classification

Manual" prepared by the Executive Office of the

President, Office of Management and Budget, which is

available from the Government Printing Office,

Washington, D.C. Use the current edition of the

manual. If you have any questions concerning the

appropriate SIC code for your facility, contact your

Department of Ecology Regional Office (see Table 1).

Table 1. Department of Ecology Regional Offices

Northwest Regional Office Southwest Regional Office

3190 - 160th Ave. SE P.O~ Box 47600

Bellevue, WA 98008-5452 Olympia, WA 98504

Tel: (425) 649-7000 Tel: (360) 407-6300

Eastern Regional Office Central Regional Office

N 4601 Monroe St., Suite 100 3601 West Washington

Spokane, WA 99205-1295 Yakima, WA 98903-1164

Tel: (509) 545-2926 Tel: (509) 558-2800

Section VII-A

Give the name, as it is legally referred to, of the person,

firm, public organization, or any other entity which

operates the facility described in this application. This

mayor may not be the same name as the facility. The

operator of the facility is the legal entity which controls

the facility's operation rather than the plant or site

manager. Do not use a colloquial name.

Section VII-B

Indicate whether the entity which operates the facility

also owns it by marking the appropriate box.

Section VII-C

Enter the appropriate letter to indicate the legal status

of the operator of the facility. Indicate "public" for a

facility solely owned by local government(s) such as a

city, town, county, parish, etc.

Sections VII- D - H

Enter the telephone number and address of the

operator identified in Item VII-A.

.,
Section X

Briefly describe the nature of your business (e.g.,

products produced or services provided).

Section XII

For hazardous debris, a description of the debris

category(ies) and contaminant category(ies) to be

treated, stored, or disposed of at the facility.

Section Xl

For a corporation, by a principal executive officer of at

least the level of vice president.

For partnership or sole proprietorship, by a general

partner or the proprietor, respectively; or

For a municipality, state, federal, or other public

facility, by either a principal executive officer or

ranking elected official.

Form 1 - Instructions (continued)

Section VIII

Include whether the facility is located on Indian lands.

Section IX

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

of the facility which clearly show the following:

.:. The legal boundaries of the facility;

.:. The location and serial number of each of your existing

and proposed intake and discharge structures;

.:. All hazardous waste management facilities;

.:. Each well where you inject fluids underground; and

•:. All springs and surface water bodies in the area,

plus all drinking water wells within 1f4 mile of the

facility which are identified in the public record or

otherwise known to you.

If 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, ifpossible. Ifnot, attach additional sheets

describing the location of the structure, disposalsite, 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 currents; and in tidal waters, show the

directions of the ebb and flow tides. Use a 711.2 minute

series map published by the U.S.Geological Survey,

which may be obtained through the U5. Geological

Survey Offices listed below. If a 711.2 minute series map

has not been published for your facilitysite, then you

may use a 15minute series map from the U.S.Geological

Survey. If neither a 7lf.2 nor 15 minute series map has

been published for your facility site, use a plat map or

other appropriate map, including all the requested

information; in this case, briefly describe land uses in the

map area (e.g.,residential, commercial).

You may trace your map from a geological survey

chart, or other map meeting the above specifications. If

you do, your map should bear a note showing the

number or title of the map or chart it was traced from.

Include the names of nearby towns, water bodies, and

prominent points.

U.S.G.S. OFFICES

Western Mapping Center

National Cartographic

Information Center

U.S.G.S.

345 Middlefield Road

Menlo Park, CA 94025

Tel: (415)323-8111

. AREAS SERVED

Arizona, California, Hawaii,

Idaho, Nevada, Oregon,

Washington, American Samoa,

Guam, and trust territories

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ECY 030-31 Instr. (Rev. 7/97) Ecology is an Equal Opponunity and Affirmative Action employer
• FORM 1 tUHIUillll lIlt(

DH 1111(1 t OF

ECOLOGY

Washington State

DANGEROUS WASTE PERMIT

GENERAL INFORMATION

(Read "Form 1 lnstructions" before starting)

I. EPA/State 1.0. No.

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II. NAME OF FACILITY

r 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

III. FACILITY CONTACT

A. Name and Title (last first & title) B. Phone (area code & no.) I I , , I I , I , I 1 I I , I I , , : I I I I , I , I I I

, I III'

,

'II' i

I

N. FACILITY MAILING ADDRESS

A. Street or P.O. Box

I I I , , I , I 1 , 1 I I I I , I I I I I I I , I I I , I I J I I I I I I

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B. City or Town C. State D. Zio Code

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 'II III I I I I I J I I 1

,

V. FACILITY LOCATION

A. Street Route No. or Other Specific Identifier

1 , 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 I I I I I I I I J I I I

B. County Name

n 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

C. City or Town D. State . Zio Code EO un~f~«il~

1 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 -

:

VI. SIC CODES (4-digit, in orderofpriority)

A. First B. Second

1 I I I (specify) I I I I I (specify)

C. Third D. Fourth

1 I I I (specify) I I I I , (specify)

VII. OPERATOR INFORMATION B. Is the name listed in

A.Name item VII-A also the owner?

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 I

DYES DNO ,

c. Status of Operator (E",~ che atnrropriate1_in", tbe an=r"''' if"n",- " Mmf., I n Phone (area code & no.)

F = Federal M = Public (other than federal or state) (specify) I'· I II' I I

I I I

II S = State P = Private 0 = Other (specify)

E. 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 I I I I I I I I I I I I , I

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VIII. INDIAN LAND F. Cirv or Town G. State H.ZioCode

I J 0 I I , I I I I , , ! , I I

I I , I , I Is the facilitylocated on Indian

lands? , -DYES DNO

Complete Back Page

ECY030-31 (Rev. 7/97)
IX. MAP .'

Attach to this application a topographic map of the area extending to at least one mile beyond propeny boundaries. The map must 0",I"

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 underground. Include all springs, rivers, and other

surface water bodies in the map area, See instructions for precise requirements.

X. NATURE OF BUSINESS (providea briefdescription)

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XI. CERTIFICATION (seeinstructions)

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

attachments and that, based on my inquiry ofthosepersons immediately responsible for obtaining the information contained in the

application, I believe that the information is true, accurate, and complete. I am aware that there are significant penalties for submittingfalse

information, including the possibility offine and imprisonment.

A. Name & Official Title (Type or print)

ECY030-31 (Rev. 7/97)

B.Signature C. Date Signed

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Form 3 - Instructions

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Completing This Form

Please type or print. If you print place each character

between the marks. Abbreviate if necessary to stay

within the 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 1

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. Ifthis 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.

1. 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 if:

(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

(2-b) The owner or operator had entered

into contractual obligations (options to

purchase or contracts for feasibility,

engineering, and design studies do not

constitute contractual obligations)

which could not be canceled 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% of the total project cost.

ECY 030-31 Instr, Form 3 (Rev. 7/97)

Existing Facility Date. If the Existing Facility

box is marked, enter the date dangerous waste

operations began (i.e.,the date the facility began

treating, 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, 1980.

New Facility Date. If the New Facility box is

marked, enter the date that operation began or

is expected to begin.

B. Revised Application. If this is a subsequent

application that is being filed to amend data filed

in a previous application, place an "X" in the

appropriate box to indicate whether the facility has

interim status or a permit.

1. Facility has an Interim Status Permit. Place an

"X" in this box if this is a revised application to

make changes at a facility 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,

applicantsmustresubmitin their entirety each item on

the application for which changes are requested. In

addition, Items I and IX[and Item X ifapplicable]

mustbe completed. Itis notnecessary to resubmit

infonnation for otheritems that willnot change.)

Section III

The information in Section ill 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 capacity of injection wells and

landfills at existing facilities should be measured as the

remaining, unused capacity. See the form for the

detailed instructions to Section ill.

Section IV

The information in Section IV describes all the

dangerous wastes that will be treated, stored, or

disposed at the facility. In addition, the processes that

will be used to treat, store, or dispose of each waste

and the estimated annual quantity of each waste must

be provided. See the form for the detailed instructions

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, treatment, or

disposal operations that will be used during interim

status;

.:. The name of each operation. (Example-multiple

hearth incinerator, drum storage area, etc.);

.:. Areas of past storage, treatment, or disposal

operations;

.:. Areas of future storage, treatment;or disposal

operations; and

.:. The approximate dimensions of the property

boundaries and all storage, treatment, and disposal

areas.

Section VI

All existing facilities must include photographs that

clearly delineate all existing structures; all existing

areas for storing, treating, or disposing of hazardous

waste; and all known sites of future storage, treatment,

or disposal operations. Photographs may be color or

black and white, ground-level or aerial. Indicate the

date the photograph was taken on the back of each

photograph.

ECY 030-31 Insrr. Form 3 (Rev. 7/97)

Section VII

Enter the latitude and longitude of the facility in

degrees, minutes, and seconds. For larger facilities, C

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 the U.S.

Department of Interior, Geological Survey and from

state agencies such as the Department of Natural

Resources.

Section VIII

See the form for the instructions to Section vm.

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 Section 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 0

facility, by either a principal executive officer or

ranking elected official.

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• FOR OFFICIAl USE ONLY

FORM 3 DANGEROUS WASTE PERMIT APPLICATION

I. EPA/State 1.0. No.

I I I I I i I I I I I I I

Application

Ao: roved

Date Received

(month/ day / year) Comments

I I I I I

II. FIRST OR REVISFD APPLICATION

Place an "X" in the appropriate box in A or B below (mark one box only) to indicate whether this is the first application you are

submitting for your facility or a revised application. If this is your first application and you already know your facility's EPA/STATE

J.D. Number or If this is a revised aoolication enter vour facility's EPNSTATE J.D. Number in Section I below.

A. First Application (place an "X" below and provide the appropriate date)

For new'facilities, provide the

date (mo/day/yr) operation

began or is expected to begin.

D 1. Existing Facility (See instructions for D 2. New Facility (Complete item below.)

definition of "existing" facility. Complete item below.)

For existing facilities, provide the

rn

° EDffiR date (mo/day/yr) operation began

I or the date construction commenced.

(Use the boxes to the left.)

B. Revised Application (Place an "X" below and complete Section 1 above.)

D 1. Facility has an interim Status Permit D 2. Facility has a Final Permit

•

III. PROCESSES - CODES AND DESIGN CAPACITIES

A. Process Code - Enter the code from the list-of process codes below that best describes each process to be used at the

facility. Ten lines are provided for entering codes. If more lines are needed, enter the code(s) in the space provided. If a

process will be used that is not included in the list of codes below, then describe the process (including its design capacity)

in the space provided on the (Section III-C).

B. Process Design Capacity - For each code entered in column A, enter the capacity of the process.

1. Amount - Enter the amount.

2. Unit of Measure - For each amount entered in column B(l), enter the code from the list of unit measure codes below

that describes the unit of measure used. Only the units of measure that are listed below should be used.

PROCESS PROCESS CODE APPROPRIATE UNITS OF MEASURE FOR

PROCESS DESIGN CAPACITY

Other (Usefor physical, chemical, thermal or biological treatment

processes not occurring in tanks, surface impoundments or incinerators. Describe theprocesses in thespace provided; Section III-C)

SO1" Gallonsor liters

S02 Gallonsor liters

S03 Cubic yardsor cubicmeters

S04 Gallonsor litters

T01 Gallonsper dayor liters per day

T02 Gallonsper dayor liters per day

T03 Tons per hour or metric tons per hour; gallons

per hour or liters per hour

T04 Gallonsper dayor liters per day

D80 Gallonsor liters

D81 Acre-feet (the volumethat wouldcover one acre

to a depth of one foot) or hectare-meter

D82 Acresor hectares

D83 Gallonsper dayor liters per day

D84 Gallonsor liters

Units of Measure Unit of MeasureCode

Acre-Feet , A

Hectare-Meter . . . , . . . . . . . F

Acres .. , B

Hectares , Q

Units of Measure Unit of MeasureCode

Liters Per Day, . . . . . . . . . . . V

Tons Per Hour D

MetricTons Per Hour . . . . . . . W

Gallons Per Day. . . . . . . . . . , E

Liters Per Hour , . . . . . . . . . . H

STORAGE:

Container(barrel, drum, etc.)

Tank

WastePile

Surface Impoundment

DISPOSAL:

InjectionWell

Landfill

LandApplication

OceanDisposal

Surface Impoundment

TREATMENT:

Tank

Surface Impoundment

Incinerator

Units of Measure Unit of Measure Code

Gallons .. , , .. G

Liters , L

CubicYards . . . . . . , . . . , . . Y

CubicMeters ...."...... C

•

Gallons Per Day . . . .'. . . . . . . U

ECY030-31 Form 3 (Rev, 7/97) PAGE10F6
III. PROCESSES - CODES AND DESIGN CAPACmES (continued)

Example for Completing Section ill (shown in line numbers X-I and X-2 below): .A facility has two storage tanks, one tank can

hold 200 gallons and the other can hold 400 gallons. The facilirv also has an incinerator that can bum up to 20 gallons per hour.

B. Process Design Capacity

Line A. Process Code 2. Unit of Measure

No. (from list above) 1. Amount (specify) (enter code) For Official Use Only

X-I S 0 2 600 G

X-2 T D 3 20 E .-

1

2

3

4

5

6

7

8

9

10

C. Space for additional process codes or for describing other process (code "1'04"). For each process entered here :

include design capacity.

IV. DESCRIPTION OF DANGEROUS WASTES

A. Dangerous Waste Number - Enter the 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 total

annual quantity of all the non-listed waste(s) that will be handled which possess that characteristic or contaminant.

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ECY 030-31 Form 3 (Rev. 7/97) PAGE 2 OF6
DESCRIPTION OF DANGEROUS WASTES (continued)

C. Unit of Measure - For each quantity entered in column B, enter the unit of measure code.

must be used and the appropriate codes are:

•

IV.

ENGLISH UNIT OF

MEASURE

Pounds

Tons

CODE

P

T

METRIC UNIT OF MEASURE

Kilograms

Metric Tons

Units of measure which

CODE

K

M

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If facility records use any other unit of measure for quantity, the units of measure must be convened into one of the

required units of measure taking into account the appropriate density or specific gravity of the waste.

D. PROCESSES

1. Process Codes:

For listed dangerous waste: For each listed dangerous waste entered in column A, select the code(s) from the list of process codes

contained in Section III·to indicate how the waste will be stored, treated, and/or disposed of at the facility.

For non-listed dangerous waste: For each characteristic or toxic contaminant entered in column A, select the code(s) from the list

of process codes contained in Section III to indicate all the processes that will be used to store, treat, and/or dispose of all the

non-listed dangerous wastes that possess that characteristic or toxic contaminant.

Note: Four spaces are provided for entering process codes. If more are needed: (1) Enter the first three as described above; (2)

Enter "000" in the extreme right box of Item IV-D(I); and (3) Enter in the space provided on page 4, the line number and the

additional code(s).

2. Process Description: If a code 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 - Dangerous wastes that can be described by more

than one Waste Number shall be described on the form as follows:

1. Select one of the Dangerous Waste Numbers and enter it in column A. On the same line complete columns B, C, and

D by estimating the total annual quantity of the waste and describing all the processes to be used to treat, store, and/or

dispose of the waste.

2. In column A of the next line, enter the other Dangerous Waste Number that can be used to describe the waste.

In column D (2) on that line, enter "included with above" and make no other entries on that line.

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

Example for completing Section IV (shown in line numbers X-I, X-2, X-3, and X-4 below) - A facility will treat and dispose of

an estimated 900 pounds per year of chrome shavings from leather tanning and finishing operation. In addition, the facility will

treat and dispose of three non-listed wastes. Two wastes are corrosive only and there will be an estimated 200 pounds per year of

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

will be in an incinerator and disposal will be in a landfill.

D. Processes

Line A. Dangerous B. Estimated Annual C. Unit of

No. Waste No. Quantity of Waste Measure 1. Process Codes 2. Process Description (enter code) (enter code) (enter) (ifa code is not entered in D(l))

X-I K 900 P TIO~ -d s'o I I I I

0 5 4

T'013 DlglO I I I I

X-2 D 0 0 2 400 P

X-3 D 100 P T

IO l3

Dg'O I I. I I

0 0 1

T

IO l3 DlglO I I I I included with above X-4 D 0 0 2

ECY 030-31 Form 3 (Rev. 7/97) PAGE 3 OF6
0 ;

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b f I' 'f h th 26 r PhotOCOPV IS thO page e ore comp etmq I you ave more an wastes to 1St.

J.D. Number (enter from fJal!e I)

I I I I I I I I I I I

IV. DESCRIPTION OF DANGEROUS WASTES (continued)

D. Processes

Line A. Dangerous B. Estimated Annual C. Unit of

No. Waste No. Quantity of Waste Measure

(enter.code) (entercode) 1. Process Codes 2. Process Description

(enter) (ifa codeisnot enteredin D(1))

I I I I I I I I

1

I I I I I I I I

2 I

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3

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ECY 030-31 Fonn 3 (Rev. 7/97) PAGE40F6
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IV. DFSCRIPTION OF DANGEROUS WASTES (continued)

E. Use this space to list additional process codes from Section D(l) ~n page 3.

V. FACIIlTYDRAWING

All existingfacilities must include in the space provided on page5 a scaledrawing of the facility (see instructions for more detail).

VI. PHOTOGRAPHS

All existingfacilities must include photographs (aerialor ground level) that clearlydelineate all existing structures; existing storage,

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

VII. FACIliTY GEOGRAPHIC LOCATION

LATITUDE 'degrees, minutes &seconds I LONGITUDE (deerees minutes, &second;

I II I Ii I I II II I II

VIII. FACIIlTY OWNER

0 A. If the facility owner is also the facility operator as listed in Section VII on Form 1, "General Inforamtion," place an "X"

in the box to the left and skip to Section IX below.

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

1. Name of Facility's Legal Owner 2. Phone Number (area code&no.l I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

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

3. Street or P.O. Box 4. City or Town 5. St 6. 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 I I I I I I I I I I I

I 1

IX. OWNER CERTIFICATION

I certify underpenalty ofUw thatI havepersonally examined andamfamiliarwith theinformation submittedin thisand allattached

documents, and thatbased on my inquiryofthose individuals immediately responsible for obtainingtheinformation, I believe thatthe

submitted information istrue, accurate, and complete. I amaware thatthere aresignificantpenaltiesforsubmittingfalse information,

includinethepossibility offineand imtmsonment:

Name (print or type) Signature Date Signed

X. OPERATOR CERTIFICATION

I certify underpenalty oflawthatI havepersonally examinedandamfamiliarwith theinformation submittedin thisand allattached

documents, and thatbased on my inquiryofthose individuals immediately responsiblefor obtainingtheinfonnation,I believethatthe

submitted information istrue, accurate, andcomplete. I amaware thatthere aresignificantpenaltiesforsubmittingfalse information,

including thepossibility of fineand imprisonment.

Name' (print or type) Signature Date Signed

tcr 030-31 Form 3 (Rev. 7/97) PAGES OF6
v.FACIliTY DRAWING (seepage 4)

ECY 030-31 Fom13 (Rev. 7/97) PAGE60F6

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