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r <br /> c M ' <br /> 1 <br /> f <br /> ID — For Official Use Only <br /> 'ArW 1 <br /> X. escn non of Hazardous Wastes(COfItlnued from Jront) f ti <br /> A. Hazardous Waste,from Nonspecific Sources. Entnr the four-digit number from 40 CFR Part 261 31 for each listed hazardous waste <br /> from nonspecific sources your installation handles. Use additional sheets it necessary. <br /> r <br /> __RT TTT = I I I L <br /> 1 2 3 4 5 6 <br /> 7 8 9 10 11 12 <br /> F ETT '=' -11 L - <br /> B. Hazardous Wastes from Specific Sources. Enter the four-digit number Irom 40 CfR Part 261 32 for each listed hazardous waste from <br /> specific sources your installation handles. Use additional sheets it necessary. <br /> 13 14 15 16 17 18 <br /> A-Fr TTF _F1 <br /> I FM _F <br /> 19 20 2122----------i-----------1__T 1-- 23 4 <br /> IT <br /> I L -FtTl <br /> 25 26 27 28 29 30 <br /> ET- [T[_11 EFTT' 'TF-11 I FF _ __FFF <br /> .1 <br /> C. Commercial Chemical Product Hazardous Wastes. Enter the four-diq t number from 40 CFR Part 261.33 for each chemical substance <br /> your installation handles which may be a hazardous waste Use additional sheets if necessary. <br /> 31 33 34 35 36 <br /> tTrFI <br /> =I - <br /> 39 40 41 42 <br /> :TT I AI I - <br /> - --------------- <br /> 45 46 47 48 <br /> FTF T, i DAT <br /> D. Listed Infectious Wastes. Enter the ,:u:-digit number from 40 CFR Part 261 34 for each hazardous waste from hospitals,veterinary hos- <br /> pitals,or medical and research labo. -:., es your installation handles. Use additional sheets if necessary. <br /> 49 50 51 52 53 54 <br /> FF1_ <br /> E. Characteristics of Nonlisted Hazardous Wastes. Mark Xin the bores corresponding to the characteristics of nonl sted hazardous wastes <br /> your installation handles.(See 40 CFR Parrs 261.21 —261.24) <br /> ❑ 1. Ignitable ❑ 2. Corrosive ❑ 3. Reactive <br /> /00011 (D0021 ❑ 4 Toxic <br /> IDOOJI i Dt7O01 <br /> XI. Certification 4,V11' }. <br /> l certify under penalty of law that 1 have personally examined and am familiar with the Information submitted In <br /> this and all attached documents, and that based on my inquiry of those individuals Immediately responsible for <br /> obtaining the Information, l believe that the submitted information Is true, accurate, and complete. l am aware that <br /> there are significant penalties for submitting false information, including rhe possibility of fine and imprisonment <br /> Signs u re Name and Official Title(type or prrntl Date Signed <br /> EPA Form 8700-12 (Rev. 11-85) Reverse <br />