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EPA ID No. CA2890090002 CMBu: 2050-0024 Expires 111302011 EPA ID No. CA2890090002 D. Eligible Academic Entitles with Laboratories -Notification for opting Into or withdrawing from managing labaoralory hazardous wastes pursuant to 40 CFR Part 262 Subpart K * You must check with your Stale to delernlne It you are eligible to manage laboratory hazardous wastes pursuant to 40 CFR Part 262 Subpart K 1. Opting Into or currently operating under 40 CFR Part 262 Subpart K for the mangement of hazardous wastes In laboratories See the Item4ly4tam Instrucllons for definitions of types of eligible academic entitles. Mark all that apply: a. College or University b. Teachng Hispital ghat is owned by or has a formal written affiliation agreement with a college or university C. Non-pmlil Institute that is owned by or has a formal written affiliation agreement with a collage or university 2. Withdrawing from 40 CFR Part 262 Subpart K for the mangemenl of hazardous wastes In laboratories 11. Description of Hazardous Wastes A. Waste Codes for Federally Regulated Hazardous Wastes. Please list Naz e waste codes of the Federal hazardous wastes handled at your site. List them In the order they aro presented in the regulations (e.g., D001, 0003, F007, U112). Use on additional page if more spaces are needed. D001 D002 D003 D004 D005 D006 D007 D008 D009 D010 D011 D016 D035 D040 U031 U112 U154 U228 I B. Waste Codes for State -Regulated (i.e., non -Fader il) Hazardous Westar. Please list the waste codes of the State -regulated hazardous wastes handled at your silo. Usl them In the order they are presented In the regulations. Use an additional page It more spaces ate needed. 122 132 141 151 181 212 221 223 331 343 351 352 491 512 723 724 741 751 791 792 EPA Form 8700-12, 8700-13 A/B , 8700.23 (Revised 11/2C09) Page 3o167 OMBN: 2050-0024 Expires 11/302011 12 Notification of Hazardous Secondary Material (HSM) Activity Y ❑ NE Are you notifying under 40 CFR 260.42 that you will begin managing, are managing or will stop managing hazardous secondary material under 40 CFR 261.2(a)(2)QQ, 40 CFR 261.4(x)(23). (24), or (25)7 It yes', your must fill out the Addendum to the She Identification Form: Notification for Managing Hazardous Seocndary Material. 13. Comments 14. Certification. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision In accordance with a system designed to assure that qualKed personnel properly gather and evaluate the Information submitted. Based on my Inquiry of she person or persons who manage the system, or those persons direcly responsible for gathering the informaiion, the Information submitted Is, to the best of my knowledge and ballet, true, accurate and complete. I am aware that there are significant penalties for submitting false information, Including the possibility of fine and imprisonment for knowing violations. For the RCRA Hazardous Waste Part A Permit Application, all owner(s) and operalor(s) must sign (see 40 CFR 270.10(b) and 270.11). Signature of owner, operator, Name and Offlolaf Title (type or print) Date Signed or 1 r Pres—taliv. (mm/dd/yyyy) Joseph G Byrne, SNE 02/28/2012 Brian Perkins, Division Leader 02/28/2012 EPA Form 8700-12, 8700-13 A/B 8700-23 (Revlsed 11/2009) Page 4 of 67