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EPA ID Number C AlLl 10 1 0 1 0! 2 1 8 1 9 13 17 1 5 OMBM 2050-0024; Expires 01/31/2017 10. 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. Y❑✓ N❑ Y 1. Generator of Hazardous Waste � � 5. Transporter of Hazardous Waste If"Yes,"mark only one of the following—a, b, or c. N If"Yes,"mark all that apply. Ca a. LQG: Generates, in any calendar month, 1,000 kg/mo ❑ a. Transporter (2,200 lbs/rno.)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 (2.2 lbs/rno)of acute hazardous waste;or Y[2✓ N Generates, in any calendar month,or O 6. Treater, Storer, or Disposer of Hazardous accumulates at any time, more than 100 kg/mo Waste Note:ir hazardous waste Part B (220 Ibs/mo)of acute hazardous spill cleanup permit is required for these activities. material. Y❑ N d 7. Recycler of Hazardous Waste 100 to 1,000 kg/rno(220—2,200 lbs/mo)of ❑b. SQG: non-acute hazardous waste. ❑c. CESQG: Less than 100 kg/mo(220 lbs/mo)of non-acute Y[j N O 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. ❑ a. Small Quantity On-site Burner Exemption ❑ b. Smelting, Melting,and Refining Y❑ NF,-/] 2. Short-Term Generator(generate from a short-terra or one-time Furnace Exemption event and not frorn on-going processes). If"Yes,"provide an explanation in the Comments section. Y❑ N❑✓ 3. United States Importer of Hazardous Waste Y❑ N❑J 9. Underground Injection Control Y❑ N [✓ 4. Mixed Waste(hazardous and radioactive)Generator YE] N 2✓ 10. Receives Hazardous Waste from Off-site B. Universal Waste Activities;Complete all parts 1-2. C. Used Oil Activities; Complete all parts 1-4. Y N F,-/] 1. Large Quantity Handler of Universal Waste (you Y❑ N 2✓ 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) Y7 NQ 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 0 3. Off-Specification Used Oil Burner f. Other(specify) ❑ Y N D4. Used Oil Fuel Marketer g. Other(specify) ❑ If"Yes,"mark all that apply. Y r_� N F,_(j 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 Farm 8700-12, 8700-13 A/B, 8700-23 Page 2 of 4