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EPA ID Number C A D 0 0 9 1 814 5 0 8 OMB#2050-0024; Expires 05/31/2020 12. Eligible Academic Entities with Laboratories—Notification for opting into or withdrawing from managing laboratory hazardous wastes pursuant to 40 CFR 262 Subpart K. r]Y ❑✓ N A.Opting into or currently operating under 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories—If"Yes", mark all that apply. Note:See the item-by-item instructions for defini- tions of types of eligible academic entities. 1.College or University 2.Teaching Hospital that is owned by or has a formal written affiliation with a college or university 3. Non-profit Institute that is owned by or has a formal written affiliation with a college or univer- []Y Z N B.Withdrawing from 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories. 13. Episodic Generation Fly ❑V N Are you an SQG or VSQG generating hazardous waste from a planned or unplanned episodic event, lasting no more than 60 days,that moves you to a higher generator category.If"Yes",you must fill out the Ad- dendum for Episodic Generator. 14. LQG Consolidation of VSQG Hazardous Waste 11Y Z N Are you an LQG notifying of consolidating VSQG Hazardous Waste Under the Control of the Same Person pursuant to 40 CFR 262.17(f)?If"Yes",you must fill out the Addendum for LQG Consolidation of VSQGs hazardous waste. 15. Notification of LQG Site Closure for a Central Accumulation Area(CAA)(optional)OR Entire Facility(required) []Y Z N I LQG Site Closure of a Central Accumulation Area(CAA)or Entire Facility. A.❑Central Accumulation Area(CAA)`D Entire Facility B. Expected closure date: mm/dd/yyyy C. Requesting new closure date: mm/dd/yyyy D. Date closed : mm/dd/yyyy 1. In compliance with the closure performance standards 40 CFR 262.17(a)(8) 2. Not in compliance with the closure performance standards 40 CFR 262.17(a)(8) 16. Notification of Hazardous Secondary Material(HSM)Activity ❑y FON A.Are you notifying under 40 CFR 260.42 that you will begin managing,are managing,or will stop manag- ing hazardous secondary material under 40 CFR 260.30,40 CFR 261.4(a)(23), (24),or(27)?If"Yes",you must fill out the Addendum to the Site Identification Form for Managing Hazardous Secondary Material. Ely IN B.Are you notifying under 40 CFR 260.43(a)(4)(iii)that the product of your recycling process has levels of hazardous constituents that are not comparable to or unable to be compared to a legitimate product or intermediate but that the recycling is still legitimate?If"Yes",you may provide explanation in Comments section.You must also document that your recycling is still legitimate and maintain that documentation on site. 17. Electronic Manifest Broker Ely r,(]N Are you notifying as a person,as defined in 40 CFR 260.10,electing to use the EPA electronic manifest sys- tem to obtain,complete,and transmit an electronic manifest under a contractual relationship with a haz- ardous waste generator? EPA Form 8700-12,8700-13 A/B,8700-23 Page 5 of 7