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EPA ID Number <br />OMB#: 2050-0024; Expires 11/30/2011 <br />12. Notification of Hazardous Secondary Material HSM Activity <br />Y ❑ Nr Are you notifying under 40 CFR 260.42 that you will begin managing, are managing, or will stop managing hazardous <br />secondary material under 40 CFR 261.2(a)(2)(ii), 40 CFR 261.4(a)(23), (24), or (25)? <br />If "Yes", you must fill out the Addendum to the Site Identification Form: Notification for Managing Hazardous Secondary <br />Material, <br />13. Comments <br />14. Certification. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in <br />accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based <br />on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the <br />information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant <br />penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. For the RCRA <br />Hazardous Waste Part A Permit Application, all owner(s) and operator(s) must sign (see 40 CFR 270.10(b) and 270.11). <br />Signature of legal owner, operator, or an <br />authorized representative <br />Name and Official Title (type or print) <br />Date Signed <br />(mm/dd/yyyy) <br />i <br />t> <br />EPA Form 8700-12, 8700-13 A/B, 8700-23 (Revised 11/2009) <br />Page 4 of I <br />