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1 . Na meo f F a c ili ty N a me o f O w n e r F a c i l ity 2 . E P A Id e n tif ic a tio n Nu m b er ( i f al r ead yas s i g n ed u n d er R C R A ) 3 . F a ci l i t y M a i l i n g Ad dr e s s ( S t r ee t or

P O B o x , C i t y , S t at e, & Z

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bo x. Se e In s tr u c ti o ns . ) A. Ge n e r a t o r w/ o n s i t e s t o r a g e f a ci l i t y C . T r a n s por t e r E . A p p r ove d D i s p o s e r B . S t ore r ( C omme r c i a l ) D . R & D /T re a ta b i l ity F . Sc r a p M e ta l R e c o v e r y O v e n /S me l t e r , Hi g h Effi c i e n c y B o i l e r s 7 . C e r tif

ic a tio n Un der c i v i l a n d cr imi na l pe n a l t i e s o f l a w f o r t h e m ak i n g o r s ubm i s s io n o f f

a l s e o r f r audu l e nt s t at eme nt s o r

re pre s e nt at io n s (18 U . S . C . 1001 an d 1 5 U . S . C . 2615), I c er t i f y t h at t h e inf o r

m a t i o n c o n t ai n e d i n or acco m p a nyi ng t h i s do cu m e nt i s t rue, accur at e , an d co m p l e t e . A s t o t h e id e nt i f i ed se ct io n ( s) o f t h i s d o c u me nt f o r w h i c hI c an n o t p e r s on al l y v e r i f y

tru th an d a c c u r a cy , I c e r ti f yas a compa n y o f fici a l having s uper v i s o r y r e s p o n s ib ilit y f o rt h e per s o n s wh o , acti ng u n der m y d i r ect i n s t ru ct io ns , ma de t h e v e r i f i c a t i o n t h at t h i s i n f o r m at io n i s t rue, accur at e , an d co m p l e t e . S i g n at u r e N ame a nd O f f i c i a l T i t l e ( T y p e o f Pr i nt ) D a t e S i g n ed Pap e r w or k Re d u cti o n Act Noti ce T h e a n nu a l pu bli c b u r d e n f

o r t h i s co l l e ct io n o f i n f o r mat io n i s e s t i m at e d t o av er ag e 0. 57 h o ur s per r e spo n se. T h i s est i m at e i n c ludes t i me f o r re a di ng ins truc t i o ns , s ear c h i ng e x i s t i n g data s o u r ces , gat h er i ng an d m a i nt a i n i ng t h e n eed ed data, a nd c ompl e t i n g an d r e v i e w in g c o lle c t io n o f in f o r m at io n. S e n d co mme nt s r e gar d i n g t h e b u r d e n est i m at e o ra n yo t h e raspect o f t h i s co l l e ct io n o f i n f o r m at io n , i n c lud i ng s ugges t io n s f o r red u c i n g the burd en to: D i r e c t o r , C o l l ect io n Str at e gi es D i v i s io n , U. S. E nvir o nme nt a l Pr ot ect io n A g e n c y( m a i lco de 2822) , 1200 Penns y l v a n i a Ave. , N. W . , Was hi ngt o n , D. C . 20460- 0001 . I n c lude t h e OM B nu m b er i d e nt i f i ed a b o v e i n a n yco rr e s p o n de nce. Do n o tsen dt h e c om p leted f

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m to th is ad d r es s . The ac tu a l inf o r m at io n o r f

o r m s h o u ld b e su bm it t e d i n acco r d ance w it h t h e i n st ru ct io n s ac co m p a nyi ng t h e f o r m , o r as sp ec i f i e d i n t h e c o rres pondi n g r e gu l a t i o n s . 

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- 5 3 ( R e v . 6 / 0 2) P r e vio u s e ditio n s a r e o b s o le te .Item-by-Item Instructions for Completing EPA Form 7710-53 Return completed form to: Fibers & Organics Branch (7404T) Office of Pollution Prevention & Toxics U.S. Environmental Protection Agency 1200 Pennsylvania Ave., N.W. Washington, DC 20460-0001 Fax: 202-566-0473 No information on the form may be claimed confidential. Type or print in black ink all items, except Item VII, “Certification.” If you must use additional sheets, indicate clearly th e number of the item on the form to which the information on the separate sheet applies. Item 1 -- Name of facility: Enter the name of the facility and the name of the owner of the facility. Item 2 -- EPA identification number (if already assigned under RCRA): Enter the identification number the facility was assi gned under the RCRA hazardous waste notification regulations. If no identification number has been assigned, leave this space blank. A notifier may use their RCRA Identification number prior to receipt of written verification from EPA once they have confirmed that EPA is in receipt of their PCB notification form. Confirmation of receipt of the form may be accomplished by submitting it through the U.S. mail -- return rec eipt requested, telephoning to confirm receipt of mail or facsimile, commercial overnight carrier’s delivery verification processes, or any oth er manner in which the submitter can demonstrate in that the form was received by EPA Headquarters. Items 3 and 4 -- Facility mailing address and location: Complete Items III and IV. Please note that the address you giv e in Item IV, “Location of Facility,” must be a physical address, not a post office box or route number. If the mailing address and physical location are the same, you may enter “Same” in Item IV. If the facility is a mobile incinerator, you may enter “mobile” in Item IV, and provide the mailing a ddress for the installation contact in Item III. Item 5 -- Installation contact: Enter the name, title, and business telephone number of the person who should be contacted regarding informa tion submitted on this form. Item 6 -- Type of PCB activity: Mark the appropriate box(es) to show which PCB ac tivities are tak ing pl ace at this facility. A. Generator with onsite storage facility: You are a generator with an onsite storage facility under this notification requirement if you are a user, owner, or processor of PCBs or PCB items and you maintain your own storage facilities subject to 40 CFR 761.65(b) o r (c)(7) for PCBs. If you are a generator with an onsite storage facility, mark an “X” in this box. B. Commercial Storer: You are a commercial storer if you own or operate a storage facility which is subject to the storage facility standards of 40 CFR 761.65(b) or (c)(7), and which engages in off-site storage activities involving the PCB wastes generated by others. Most commercial storers of PCB waste perform waste storage services in exchange for a fee or other compensation, but the receipt of compensation is not necessary for your storage facility to qualify as a commercial storer of PCB wastes generated by others. See definition of commercial storer in 40 CFR 761.3. If you are a commercial storer, mark an “X” in this box. C. Transporter: If you move PCBs by air, rail, highway, or water, then mark an “X” in this box. D. R&D/Treatability: If you are engaged in conducting R&D into PCB disposal tec hnologies and cannot accept waste on a commercial scale, mark an “X” in this box. You should also check this box if you conduct treatability studies even though you ma y have marked the “Approved Disposer” box. E. Approved Disposer: If you currently hold a valid EPA permit to dispose of PCBs in concentrations exceeding 50 ppm in a landfill, through alternative technology or incineration, mark an “X” in this box. F. Scrap Metal Recovery Oven/Smelter, High Efficiency Boilers: If you operate a device to dispose of PCBs, or if you dispose of PCBs in compliance with Section 761.71 (i.e., high efficiency boilers) or Section 761.72 (i.e., scrap metal recovery oven/smelter), mark an “X” in this box. Item 7 -- Certification: This certification must be signed by the owner, operator, or an authorized representative of the facility. An “authorized representative” is a person responsible for the overall operation of the facility (i.e., a plant manager or superintendent, or a person of equal responsibility). All notifications must include this certification to be complete. EPA Form 7710-53 Reverse (Rev.6/02)