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05/03/04 MON 07:13 FAX 209 463 6045 TEAM CALIPER <br />EPA ID NO: LJI-I LJIPJ LI 3 LO-1�►.13J <br />NM <br />OMB#: 2050-0028 Expires 1/31/2006 <br />10. Type of Regulated Waste Activity <br />Mark "Yes" or "No" for all activities; complete any additional boxes as instructed. (See instructions on pages 16 to 20.) <br />A. Hazardous Waste Activities <br />Complete all parts for 1 through 6. <br />Y ❑ N ❑ 1. Generator of Hazardous Waste <br />If "Yes", choose only one of the following - a, b, or c. <br />a. LQG: Greater than 1,000 kg/mo (2,200 lbs./mo.) <br />of non-acute hazardous waste; or <br />❑-b. SQG: 100 to 1,000 kg/mo (220 - 2,200 lbs./mo.) <br />of non-acute hazardous waste; or <br />❑ c. CESQG: Less than 100 kg/mo (220 lbs./mo.) <br />of non-acute hazardous waste <br />In addition, indicate other generator activities. <br />Y U N $d. United States Importer of Hazardous Waste <br />Y ❑ N $e. Mixed Waste (hazardous and radioactive) Generator <br />B. Universal Waste Activities <br />Y ❑ N i$ 2. Transporter of Hazardous Waste <br />Y ❑ N X 3. Treater, Storer, or Disposer of <br />Hazardous Waste (at your site) Note: <br />A hazardous waste permit is required for <br />this activity. <br />Y ❑ N [X 4. Recycler of Hazardous Waste (at your <br />site) <br />Y ❑ N � 5. Exempt Boiler and/or Industrial <br />Furnace <br />If "Yes", mark each that applies. <br />U a. Small Quantity Ort -site Burner <br />Exemption <br />❑ b. Smelting, Melting, and Refining <br />Furnace Exemption <br />Y ❑ N � 6. Underground Injection Control <br />C. Used Oil Activities <br />Mark all boxes that apply. <br />Y ❑ N �J. Large Quantity Handler of Universal Waste (accumulate <br />5,000 kg or more) [refer to your State regulations to Y ❑ N 1 1. Used Oil Transporter <br />determine what is regulated]. Indicate types of universal If "Yes", mark each that applies. <br />waste generated and/or accumulated at your site. If "Yes", IJ a. Transporter <br />mark all boxes that apply: ❑ b. Transfer Facility <br />a. Batteries <br />b. Pesticides <br />c. Thermostats <br />d. Lamps <br />e. Other (specify) <br />f. Other (specify) <br />g. Other (specify) <br />Generate Accumulate <br />Y ❑ N � 2. Used Oil Processor and/or Re -refiner <br />❑ if "Yes", mark each that applies. <br />❑ a. Processor <br />❑ ❑ b. Re -refiner <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Z <br />❑ <br />❑ <br />❑ <br />Y ❑ N ❑ 2. Destination Facility for Universal Waste <br />Note: A hazardous waste permit may be required for this activity. <br />EPA Form 8700-12 (Revised 1/2004) <br />Y ❑ N � 3. Off -Specification Used Oil Burner <br />Y ❑ N � 4. Used Oil Fuel Marketer <br />If "Yes", mark each that applies. <br />❑ a. Marketer Who Directs Shipment of <br />Off -Specification Used Oil to <br />Off -Specification Used Oil Burner <br />❑ b. Marketer Who First Claims the <br />Used Oil Meets the Specifications <br />Page 2 of 3 <br />