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EPA ID Number I C I A I L 1 0 1 0 1 0 12 16 9 3 7 5 OMB#: 2050-0024; Expires 01/31 /2017 W. Type of Regulated Waste Activity (at your site) Mark "Yes" or "No" for all current activities (as of the date submitting the form); complete any additional boxes as instructed. A. Hazardous Waste Activities; Complete all parts 1 -10. 1 . Generator of Hazardous Waste 5. Transporter of Hazardous Waste Y ❑✓ Y ❑ N ❑✓ If "Yes," mark all that apply. U a. LQG: Generates, in any calendar month, 1 ,000 kg/mo ❑ a. Transporter (2,200 lbs/mo.) or more of hazardous waste; or Generates, in any calendar month, or ❑ b. Transfer Facility (at your site) accumulates at any time, more than 1 kg/mo lbs/mo) of acute hazardous waste; or Generates, in any calendar month, or Y❑✓ N ❑ 6. Treater, Storer, or Disposer of Hazardous Ge accumulates at any time, more than 100 k (220 lbs/mo) of acute hazardous spill cleanupnup permit is required for these activities.Waste Note: A hazardous waste Part B material. Y ❑ NE 7. Recycler of Hazardous Waste 100 to 1 ,000 kg/mo (220 — 2,200 lbs/mo) of ❑ b. SQG: non-acute hazardous waste. ❑ c. CESQG: Less than 100 kg/mo (220lbs/mo) of non-acute Y ❑ N 8. Exempt Boiler and/or Industrial Furnace hazardous waste. If "Yes," mark all that apply. If "Yes" above, indicate other generator activities in 2-10. Ll Exemption Small Quantity On-site Burner Exemption ❑ b. Smelting, Melting, and Refining Y ❑ N ❑✓ 2. Short-Term Generator (generale from a short-term or one-time Furnace Exemption event and not from on-going processes) . If "Yes," provide an explanation in the Comments section. Y ❑ N 0 3. United States Importer of Hazardous Waste Y ❑ N ❑✓ 9. Underground Injection Control Y ❑ N ❑✓ 4. Mixed Waste (hazardous and radioactive) Generator Y ❑ N ❑✓ 10. Receives Hazardous Waste from Off-site B. Universal Waste Activities; Complete all parts 1 -2. C. Used Oil Activities; Complete all parts 14. Y ❑ N ❑✓ 1 . Large Quantity Handler of Universal Waste (you YON ❑✓ 1 , Used Oil Transporter accumulate 5,000 kg or more) [refer to your State If "Yes," mark all that apply. regulations to determine what is regulated]. Indicate ❑ a. Transporter types of universal waste managed at your site. If "Yes," mark all that apply. ❑ b. Transfer Facility (at your site) Y ❑ N ❑✓ 2. Used Oil Processor and/or Re-refiner a. Batteries ❑ If "Yes," mark all that apply. b. Pesticides ❑ ❑ a. Processor c. Mercury containing equipment ❑ ❑ b. Re-refiner d. Lamps e. Other (specify) ❑ Y ❑ N 3. Off-Specification Used Oil Burner f. Other (specify) ❑ Y N 4. Used Oil Fuel Marketer ❑ ❑✓ g. Other (specify) ❑ If "Yes," mark all that apply. Y ❑ N ❑✓ 2, Destination Facility for Universal Waste ❑ a. Marketer Who Directs Shipment of Note: A hazardous waste permit may be required for this Off-Specification Used Oil to activity. Off-Specification Used Oil Burner ❑ b. Marketer Who First Claims the Used Oil Meets the Specifications EPA Form 8700-12, 8700- 13 A/B, 8700-23 Page 2 of 4