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Form Appmve . OMB No, 2050-0028 Ewoves 9-30-% <br />Please print or type with ELITE type (1.,,— t,,ers per inch) in the unshaded areas only SSA No. c246 E?A-e* <br />EPA Form 8700.12 (Rev. 11-30-93) Previous edition is obsolete. <br />ID - For Official Use Only <br />Vlll. Type of Regulated Waste Activity (Mark 'X' in the appropriate boxes; Rater to Instructions) <br />A. Hazardous Waste Activity <br />B. Used Oil Recycling Activities <br />1. Generator (See Instructions) ❑ 3. Treater, Storer, Disposer (at <br />1. Used Oil Fuel Marketer <br />❑ a. Greater than 1000k9fmo (2,200 lbs.) Installation) Note: A permit Is <br />❑ a. Marketer Directs Shipment of Used <br />b. 100 to 1000 kg/mo (200.2,200 lbs.) required for this activity; see <br />Oil to Off -Specification Burner <br />❑ b. Marketer Who First Claims the Used <br />❑ taws than 100 kg/mo (220 lbs) Instructions. <br />4. Hazardous Waste Fuel <br />Oil Meets the Specifications <br />2. Transporter (Indicate Molle In boxes 1-5 <br />T M <br />below) a. Generator Marketing to Burner <br />7 Used Oil Burner - Indicate Type(s) of <br />a. For own waste only b. Other Marketers <br />1-1 a. <br />Combustion Device(sj <br />Utility Boiler <br />al Furnace <br />❑ b. For commercial proposes c. BollerantYorindwMm <br />b. Industrial Boiler <br />e 1. Smelter Deferral <br />2. Small Quantity Exemption <br />4H c. industrial Furnace <br />Mode of Transportation <br />3, Used Oil Transporter - Indicate Type(s) <br />1 Air Indicate Type of Combustion <br />of Activity(les) <br />❑ 2. Rail Device(s)a. <br />1. Utility "I" <br />Transporter <br />b. Transfer Facility <br />❑ 3. Highway ❑ <br />❑ 4. Water ❑ 2. Industrial Boiler <br />4. Used ON ProcessodRe-refiner-Indicate <br />❑ 5. Otlrer- specify ❑ 3. Industrial Furnace <br />❑ S. Underground Injection Controf <br />Type(s) of Activity(les) <br />a. Process <br />b. Re refine <br />IX. Description of Hazardous Wastes (Use additional sheets It necessary) <br />A. Characteristics of Nonlisted Hazardous Wastes. (Mark 'X' in the boxes corresponding to the characteristics of <br />nonlisted hazardous wastes your installation handles; See 40 CFR Parts 26110 - 261.24) <br />1. Igynitable 2. corrosive 3. Reactive 4. TaxlUty <br />(0001) (Dom) (Dom) Lharected0c (list species rP/A^hexavtous was Marfber(s) tur lM T"Ic" charaewWic conramtrms(s)) <br />V ` i J � Ei C- L—L-1_L} <br />B. Listed Hazardous Wastes. (See 40 CFR 261.31. 33; See instructions if you need to list more than 12 waste codes.) <br />1 2 f 3 4 <br />7 8 g 10 <br />5 6 <br />1T 12 <br />C. Other Wastes. (Stateorother wastes requiring a handler to have an I.D. number: See instructions.) <br />X. Certification <br />I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a <br />system designed to assure that qualified personnel properly gather and evaluate the Information submitted. Based on my Inquiry of the person <br />or persons who manage the system, or those persons directly responsible for gathering the Information, the Information submitted is, to the <br />best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant <br />penalties for submitting false information, <br />Including the possibility of fine and Imprisonment for knowing violations. <br />Sig ur <br />Name and Off iciaLTitle (Type or print) <br />Date Signed <br />ode ,, <br />XI. Comments <br />is (—evle1-rcl <br />e,\ '3ch,\� rta,�: <br />I ( ' <br />Note: Mail completed form to the appropriate EPA Regional or State Office. (See Section Ill of the booklet for addresses.) <br />EPA Form 8700.12 (Rev. 11-30-93) Previous edition is obsolete. <br />