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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.
.:. PartA 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 ofwaste handled at a facility during interim status canbe made without submitting a revised Part A provided the quantity does not exceed the design capacities of the processes specified in PartA 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 willbe 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 ofWashington Public Records Act chapter42.17 RCW and chapter43.21A-160 RCW. Persons filing this form maymake claims of confidentiality. Such claims mustbe clearly indicatedby marking "confidential" on the specificinformation on the form for which confidential treatmentis requested or on any attachments, and mustbe 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. Whichportions of the information do you claim are entitled to confidential treatment? B. For how long is confidential treatmentdesired for this information? C. Whatmeasures have you taken to guard against undesired disclosure of the information to others? D. To what extenthas the information been disclosed to others, and whatprecautions havebeen taken in connection with that disclosure? E. Has the Department of Ecology, EPA or any other federal or state agency made a pertinentconfidentiality determination? Ifso, what would those harmful effects be and why should they be viewed as substantial? Explain the casualrelationship between disclosure and the harmful effects. Ifno claim ofconfidentiality or no substantiation accompanies the information when it is submitted, EPA or the departmentmay 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 mustbe 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 ofcharacters allowed for each item. Use one space forbreaksbetween words, butnot for punctuationmarks unless they are needed to clarify your response. . 

### Section I 

### Space is provided at the upperright-hand comer of Form 1 for insertion ofyour EPA/State identification number. If

### you have an existing facility, enteryour identificationnumber. If

### you don'thave an EPA/ State identification number, please contact the Department of Ecology (360) 407-6000and one willbe 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 notuse 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 ofthis 

### 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. 425and 22). 

### Section VI List, in descending order ofsignificance, the four 4-digit standard industrial classification (SIC)codes which best describe your facility in terms of the principalproducts 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 maybe found in the "Standard Industrial Classification Manual" preparedby the Executive Office of the President, Office ofManagement 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 yourfacility, contact your Department ofEcology Regional Office (see Table 1).


### Table 1. Department of Ecology Regional Offices NorthwestRegional Office SouthwestRegional 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 notbe 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 notuse a colloquial name. 

### Section VII-B Indicate whether the entity which operates the facility also owns it

### by marking the appropriatebox. 

### Section VII-C Enter the appropriate letter to indicate the legal status of the operatorof the facility. Indicate "public" for a facility solely ownedby 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 ofyourbusiness (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 partneror the proprietor, respectively; or Fora municipality, state, federal, or otherpublic facility, by either a principal executive officer or ranking elected official. 

### Form 1 - Instructions (continued) Section VIII Include whether the facility is located on Indianlands. 

### Section IX Provide a topographic map or maps of the area extending at least to one mile beyond the propertyboundaries of the facilitywhich clearly show the following: .:. The legal boundaries ofthe facility; .:. The location and serial 

### numberofeach ofyourexisting and proposed intake and discharge structures; .:. All hazardous waste management facilities; .:. Each well where you inject fluids underground; and •:. All springs and surface waterbodies 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

### anintake or discharge structure, hazardous waste disposal site, or injection well associated with the facility is locatedmore than one mile from the plant, include it on the map, if

### possible. If

### not, attach additional sheets describingthe location of the structure, disposal site, or well, andidentify the U.S.GeologicalSurvey (or other) map corresponding to the location

.. Oneach map, include the map scale, ameridian arrow showingnorth, and latitude and longitude at the nearestwhole second. On all 

### maps of rivers, show the direction of the currents; andin tidal waters, show the directions of the ebb andflow tides. Use a 71 

### 1.2minute series mappublishedby the U.S.Geological Survey, whichmay be 

### obtained through the U5. Geological SurveyOffices listed below. If

### a 71

### 1.2minute series map has notbeenpublished for yourfacilitysite, then you mayuse a 15minute series map from the U.S.Geological Survey. If

### neither a7lf.2 nor 15 minute series maphas beenpublished for yourfacility site, use aplatmap or otherappropriatemap, including all 

### the requested information;in this case, briefly describe landuses in the map area (e.g.,residential, commercial). You may trace yourmap from a geological survey chart, or othermap meeting the above specifications. If 

### you do, yourmap shouldbear a note showing the number or title of the map or chartit was traced from. Include the names ofnearby towns, waterbodies, and prominentpoints. 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 isan 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. FACILITYCONTACT 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. FACILITYMAILING 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
I 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 orderof priority) 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 atnrropriate 1_

# in", tbe a

# n=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 I 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 brief description)



# o

XI. CERTIFICATION (seeinstructions) I certify underpenalty of law that I have personally examinedandamfamiliarwith the information submittedin this application andall attachments andthat, based on my inquiry of thosepersons immediately responsiblefor obtaining the information contained in the application, I believe that the information is true, accurate, and complete. I am aware that there are significantpenalties for submittingfalse information, including thepossibility of fine 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. Ifyou printplace each character between the marks. Abbreviate ifnecessary to stay within the numberof characters allowed for each item. Use one space for breaks between words, butnotfor punctuationmarks 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 itemblank. 

### 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 constructionhad commenced on or before November 15, 1980. Constructionhad"commenced" only if: (1) The owner or operatorhad obtained all necessaryfederal, state, and local preconstruction approvals or permits; and (2-a) A continuous physical, on-site construction programhad begun (facility design or otherpreliminary non-physical and non-site specific preparatory activities do notconstitute an on-site constructionprogram), or (2-b) The owner or operatorhad entered into contractual obligations (options to purchase or contracts for feasibility, engineering, and design studies do not constitute contractual obligations) which couldnotbe 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. Ifthe Existing Facility box is marked, enterthe date dangerous waste operationsbegan(i.e.,the date the facilitybegan treating, storing, or disposing ofhazardous waste) or the date constructioncommenced. 2. New Facility. New facilities are all facilities for which construction commenced, or will commence, afterNovember 19, 1980. New Facility Date. If the New Facility box is marked, enter the date that operationbegan or is expected to begin. B. Revised Application. Ifthis is a subsequent application thatis 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. Facilityhas an Interim Status Permit. Place an "X" in this box ifthis 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 ifthis is a revised application to make changes at a facility for which a permithas been issued. (Note: 

### When submittingarevisedapplication, applicantsmustresubmitin 

### theirentiretyeach item on the applicationfor which changesare requested. 

### In addition, ItemsIandIX[andItemX if 

### applicable] mustbe completed. It

### is notnecessaryto resubmit infonnationfor otheritems that will

### notchange.) 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 mustbe provided as part of the description. The design capacity of injection wells and landfills at existing facilities shouldbe 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 willbe 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 nameof each operation. (Example-multiple hearth incinerator, drum storage area, etc.);
.:. Areas ofpast storage, treatment, or disposal operations; .:. Areas offuture 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 mustinclude photographs that clearly delineate all existing structures; all existing areas for storing, treating, or disposing ofhazardous waste; and all known sites offuture 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 largerfacilities, 

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enter the latitude and longitude at the approximate

.

. mid-point of the facility. You may use the map you

provided for SectionIX ofForm 1 to determine latitude and longitude. Latitude and longitude informationis also available from Regional Offices of the U.S. Department ofInterior, Geological Survey and from state agencies such as the Department ofNatural Resources. 

### Section VIII See the form for the instructions to Section

## vm. Section IX 

### and Section X All facility owners must sign Section IX. Ifthe facility will be operatedby someone other than the owner, then the operatormust 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 otherpublic 

# 0 facility, by either a principal executive officer or ranking elected official.



# ()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 isexpected to begin. 

## D 1. Existing Facility (Seeinstructions 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-ofprocess 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

- Foreach code entered in column A, enter the capacity of the process.

1. Amount

- Enter the amount. 2. Unit of Measure - Foreach 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 (Useforphysical, chemical, thermal orbiological treatment processes notoccurringintanks, 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 Unitof MeasureCode Acre-Feet , A Hectare-Meter . . . , . . . . . . . F Acres

.. , B Hectares , Q Units of Measure Unit of MeasureCode Liters PerDay, . . . . . . . . . . . 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 ofMeasure Code Gallons

.. , , .. G Liters , L CubicYards . . . . . . , . . . , . . Y CubicMeters ...."...... C Gallons Per Day . . . .'. . . . . . . U 

# •

ECY030-31 Form 3 (Rev, 7/97) PAGE10F6III. 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 ofMeasure No. (from listabove) 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 orfor describing other process (code "1'04"). Foreach 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. Ifyou 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 ofthose 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 ofall the non-listed waste(s) that will be handled which possess that characteristic or contaminant. 

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C)

ECY 030-31 Form 3 (Rev. 7/97) PAGE 2 OF6DESCRIPTION OF DANGEROUS WASTES (continued) C. Unit ofMeasure

- 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



# ••



# • Iffacility 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 ofprocess 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 ortoxic 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 ofthe 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 ofthe 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 peryear 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 ofWaste Measure 1. Process Codes 2. Process Description (enter code) (enter code) (enter) (if a code is not enteredin D(l)) X-I K 900 P

### TIO~ 

# -ds'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 TIO 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

ECY030-31 Form 3 (Rev. 7/97) PAGE 3 OF6

# 0 ;
.- 

# CJ

() r th 26 h I' 'f b f 

### thO Ph t o OCOPV IS page e ore comp etmq I you ave more an wastes to 1St. J.D. Number (enterfrom 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) (if a codeisnot enteredin D(1)) I I I I I I I I 1 I I I I I I I I 2 I I I I I I I I I 3
I I I I I I I I 4
I I I . I I I I 5
I r I I I I I I 6 I I I I I I I I 7 J I I I I I J I 8
I 9 I I I I I I I I 10 11 I I I I 12 I I I 13 I I 14 15 16 17 18 , 19 20 21 22 23 24 25 26

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 (seeinstructions 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 (seeinstructions 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 LegalOwner 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 orTown 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 certifyunder penalty of Uw thatI have personally examinedandam familiarwith theinformation submittedin thisand allattached documents, and thatbasedon my inquiryof those individuals immediately responsible for obtainingtheinformation, Ibelieve thatthe submittedinformation istrue, accurate, andcomplete. I amaware thattherearesignificantpenalties forsubmittingfalseinformation, includinethepossibility offineandimtmsonment: Name (print or type) Signature Date Signed
X. OPERATOR CERTIFICATION I certify under penalty of lawthatI have personally examinedandamfamiliarwith theinformation submittedin thisand allattached documents, and thatbasedon my inquiryof those individuals immediately responsible forobtaining theinfonnation,Ibelievethatthe submittedinformation istrue, accurate, andcomplete. I amaware thattherearesignificant penalties forsubmittingfalseinformation, includingthe possibility of fineandimprisonment. 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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