Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT For EPA Regional Use Only Date Received Month Day Year &EPA United States Environmental Protection Agency Washington, DC 20460 Hazardous Waste Permit Application Part A (Read the Instructions before starting) I. Facility's EPA ID Number (Mark 'X'in the appropriate box) A. First Part A Submission B. Part A Amendment # C. Facility's EPA ID Number D. Secondary ID Number (If applicable) II. Name of Facility II. Facility Location (Physical address not P.O. Box or Route Number) A. Street Street (Continued) City or Town State Zip Code County Code (fkmm) County Name B. Land Type C. Geographic Location D. Facility Existence Date (Enter code) LA TITUDE (Degrees, minutes, & seconds) LONGITUDE (Degrees, minutes & seconds) Month Day Year IV. Facility Mailing Address Street or P.O. Box City or Town State V. Facility Contact (Person to be contacted regarding waste activities at facility) Name (Last) (First) Job Title Phone Number (Area Code and Number) VI. Facility Contact Address (See instructions) A. Contact Address Location Mailing Other B. Street or P.O. Box City or Town State Zip Code EPA Form 8700-23 (Rev. XX/XX/99) -1 of 7- ------- Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT EPA ID Number (Enter from page 1) Secondary ID Number (Enter from page 1) VII. Operator Information (See instructions) Name of Operator Street or P.O. Box City or Town State ZIP Code Phone Number (Area Code and Number) B. Operator Type C. Change of Operator Date Changed Indicator Month Day Year VIII. Facility Owner (See instructions) A. Name of Facility's Legal Owner Street or P.O. Box City or Town State ZIP Code Phone Number (Area Code and Number) IX. NAICS Codes (in order of significance; start in left box) First Third (Description) (Description) Second Fourth (Description) (Description) X. Other Environmental Permits (See instructions) A. Permit Type (Enter code) B. Permit Number C. Description EPA Form 8700-23 (Rev. XX/XX/99) -2of7- ------- Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT EPA ID Number (Enter from page 1) Secondary ID Number (Enter from page 1) XI. Nature of Business (Provide a brief description) XII. Process Codes and Design Capacities A. PROCESS CODE - Enter the code from the list of process codes below that best describes each process to be used at the facility. Thirteen lines are provided for entering codes. If more lines are needed, attach a separate sheet of paper with the additional information. For "other" processes (i.e., D99, S99, T04 and X99), describe the process (including its design capacity) in the space provided in item XIII. B. PROCESS DESIGN CAPACITY - For each code entered in column A, enter the capacity of the process. 1. AMOUNT- Enter the amount. In a case where design capacity is not applicable (such as in a closure/post-closure or enforcement action) enter the total amount of waste for that process. 2. UNIT OF MEASURE - For each amount entered in column B(1), enter the code from the list of unit measure codes below that describes the unit of measure used. Only the units of measure that are listed below should be used. C. PROCESS TOTAL NUMBER OF UNITS - Enter the total number of units used with the corresponding process code. APPROPRIATE UNITS OF PROCESS MEASURE FOR PROCESS CODE PROCESS DESIGN CAPACITY Disposal: D79 Underground Injection Gallons; Liters; Gallons Per Day; or Liters WellDisposal PerDay D80 Landfill Acre-feet; Hectare-meter; Acres; Cubic Meters; Hectares; Cubic Yards D81 Land Application Acres or Hectares D82 Ocean Disposal Gallons Per Day or Liters Per Day D83 Surfacelmpoundment Gallons; Liters; Cubic Meters; or Disposal Cubic Yards D99 OtherStorage Any Unit of Measure Listed Below Storage: S01 Container Gallons; Liters; Cubic Meters; or Cubic Yards S02 Tank Storage Gallons; Liters; Cubic Meters; or Cubic Yards 503 Waste Pile Cubic Yards or Cubic Meters S04 Surfacelmpoundment Gallons; Liters; Cubic Meters; or Cubic Yards Storage SOS Drip Pad Gallons; Liters; Acres; Cubic Meters; Hectares; or Cubic Yards SOS ContainmentBuilding Cubic Yards or Cubic Meters Storage S99 Other Disposal Any Unit of Measure Listed Below Treatment: T01 Tank Treatment Gallons Per Day; Liters Per Day; Short Tons Per Hour; Gallons Per Hour; Liters Per Hour; Pounds Per Hour; Short Tons Per Day; Kilograms Per Hour; Metric Tons PerDay; or Metric Tons Per Hour T02 Surfacelmpoundment Gallons Per Day; Liters Per Day ; Short Tons Treatment Per Hour; Gallons Per Hour; Liters Per Hour; Pounds Per Hour; Short Tons Per Day; Kilograms Per Hour; Metric Tons PerDay; or Metric Tons Per Hou T03 Incinerator Short Tons Per Hour; Metric Tons Per Hour; Gallons Per He Mir Litprs Ppr Hour: Rtn Per Hour; Pounds Per Hour; Short Tons Per Day; Kilograms Per Hour; Gallons PerDay; Liters Per Day; Metric Tons Per Hour; or Million Btu Per Hour T04 Other Treatment Gallons Per Day; Liters Per Day; Pounds Per Hour; Short Tons Per Hour; Kilograms Per Hour; Metric Tons PerDay; Metric Tons Per Hour; Short Tons Per Day; Btu Per Hour; Gallons Per Day; Liters Per Hour; or Million Btu Per Hour 780 Boiler Gallons; Liters; Gallons Per Hour; Liters Per Hour; Btu Per Hour; or Million Btu Per Hour UNIT OF UNIT OF MEASURE MEASURE CODE Gallons G Gallons Per Hour E Gallons Per Day U Liters L Liters Per Hour H Liters Per Day V PROCESS CODE PROCESS TO* f*am&nt Kiln lol Iscrfffcrffl t\llll T82 Lime Kiln 783 Aggregate Kiln 784 Phosphate Kiln T85 Coke Oven 786 Blast Furnace 787 Smelting, Melting, ^ I y i Or Refining Furnace 788 Titanium Dioxide Chloride Oxidatior i Raartnr 789 Methane Reforming Furnace 790 Pulping Liquor Recovery Furnace T91 Combustion Device Used In The Recovery Of Sulfur Values From Spent Sulfuric Acid 792 Halogen Acid Furnaces 793 Other Industrial Furnaces Listed in 40 CFR §260.10 J 794 Containment Building - Treatment APPROPRIATE UNITS OF MEASURE FOR PROCESS DESIGN CAPACITY Gallons Per Day; Liters Per Day; Pounds Per Hour; Short Tons Per Hour; Kilograms Per Hour; Metric •• Tons Per Day; Metric Tons Per Hour; Short Tons Per Day; Btu Per Hour; Liters Per Hour; Kilograms Per Hour; or Million Btu Per Hour Gallons Per Day; Liters Per Day; Pounds Per Hour; Short Tons Per Hour; Kilograms Per Hour; ' Metric Tons Per Day; Metric Tons Per Hour; Short Tons Per Day; Btu Per Hour; Gallons Per Hour; Liters Per Hour; or Miilion Btu Per Hour Cubic Yards; Cubic Meters; Short Tons Per Hour; Gallons Per Hour; Liters Per Hour; Btu Per Hour; Pounds Per Hour; Short Tons Per Day; Kilograms Per Hour; Metric Tons Per Day; Gallons Per Day; Liters Per Day; Metric Tons Per Hour; or Million Btu Per Hour Miscellaneous (SubpartX): X01 Open Burning/Open Detonation X02 Mechanical Processing X03 Thermal Unit X04 Geologic Repository X99 Other SubpartX UNIT OF UNIT OF MEASURE MEASURE CODE Short Tons Per Hour D Metric Tons Per Hour W Short Tons Per Day N Metric Tons Per Day S Pounds Per Hour J Kilograms Per Hour R Million Btu Per Hour X Any Unit of Measure Listed Below Short Tons Per Hour; Metric Tons Per Hour; Short Tons Per Day; Metric Tons Per Day; Pounds Per Hour; Kilograms Per Hour; Gallons Per Hour; Liters Per Hour; or Gallons PerDay Gallons Per Day; Liters Per Day; Pounds Per Hour; Short Tons Per Hour; Kilograms Per Hour; Metric Tons PerDay; Metric Tons Per Hour; Short Tons Per Day; Btu Per Hour; or Million Btu Per Hour Cubic Yards; Cubic Meters; Acre-feet; Hectare-meter; Gallons; or Liters Any Unit of Measure Listed Below UNIT OF UNIT OF MEASURE MEASURE CODE Cubic Yards Y Cubic Mptprf: f? Acres R Acre-feet A Hectares Q Hectare-meter F Btu Pt *r Hour / EPA Form 8700-23 (Rev. XX/XX/99) -3of7- ------- Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT EPA ID Number (Enter from page 1) Secondary ID Number (Enter from page 1) r XII. Process Codes and Design Capabilities (Continued) _^^^^^^^^^H ^^^^^^^M EXAMPLE FOR COMPLETING ITEM XII (shown in line number X-1 below): A facility has a storage tank, which can hold 533.788 gallons. Line Number X 1 1 1 1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 A. Process Code (From list above) s 0 2 B. PROCESS DESIGN CAPACITY 1. Amount /specify) 5 3 3 m 7 8 8 2. Unit Of Measure (Enter code) G C. Process Total Number Of Units 001 For Official Use Only NO TE: If you need to list more than 13 process codes, attach an additional sheet(s) with the information in the same format as above. Number the lines sequentially, taking into account any lines that will be used for "other" processes (i.e., D99, S99, T04 and X99) in item XIII. XIII. Other Processes (Follow instructions from item XII for D99, S99, T04 and X99 process codes) ^^1 Line Number (Enter #s in seg w/XII) X 1 1 2 A. Process Code (From list above) T 0 4 B. PROCESS DESIGN CAPACITY C. P 7 1. Amount, specify, *££* Nu (Enter code) rocess 'otal mber Units . 3 4 ^^^m D. Description Of Process In-situ Vitrification EPA Form 8700-23 (Rev. XX/XX/99) -4of7- ------- Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT EPA ID Number (Enter from page 1) Secondary ID Number (Enter from page 1) XIV. Description of Hazardous Wastes A. EPA HAZARDOUS WASTE NUMBER - Enter the four-digit number from 40 CFR, Part 261 Subpart D ofeach listed hazardous waste you will handle. For hazardous wastes which are not listed in 40 CFR, Part 261 Subpart D, enter the four-digit number(s) from 40 CFR, Part 261 Subpart C that describes the characteristics and/or the toxic contaminants of those hazardous wastes. B. ESTIMATED ANNUAL QUANTITY - For each listed waste entered in column A estimate the quantity of that waste that will be handled on an annual basis. For each characteristic or toxic contaminant entered in column A estimate the total annual quantity of all the non-listed waste(s) that will be handled which possess that characteristic or contaminant. C UNITOF MEASURE - For each quantity entered in column B enter the unit of measure code. Units of measure which must be used and the appropriate codes are: ENGLISH UNIT OF MEASURE POUNDS TONS CODE P T METRIC UNIT OF MEASURE KILOGRAMS METRIC TONS CODE K M If facility records use any other unit of measure for quantity, the units of measure must be converted into one of the required units of measure taking into account the appropriate density or specific gravity of the waste. D. PROCESSES 1. PROCESS CODES: For listed hazardous waste: For each listed hazardous waste entered in column A select the code(s) from the list of process codes contained in item XII A. on page 3 to indicate how the waste will be stored, treated, and/or disposed of at the facility. For non-listed hazardous waste: For each characteristic or toxic contaminant entered in column A, select the code(s) from the list of process codes contained in item XII A. on page 3 to indicate all the processes that will be used to store, treat, and/ or dispose of all the non-listed hazardous wastes that possess that characteristic or toxic contaminant. NOTE: THREE SPACES ARE PROVIDED FOR ENTERING PROCESS CODES. IF MORE ARE NEEDED: 1. Enter the first two as described above. 2. Enter "000" in the extreme right box of item XIV-D(1). 3. Use additional sheet, enter line number from previous sheet, and enter additional code(s) in item XIV-E. 2. PROCESS DESCRIPTION: If a code is not listed for a process that will be used, describe the process in the space provided on the form (D.(2)). NOTE: HAZARDOUS WASTES DESCRIBED BY MORE THAN ONE EPA HAZARDOUS WASTE NUMBER - Hazardous wastes that can be described by more than one EPA Hazardous Waste Number shall be described on the form as follows: 1. Select one of the EPA Hazardous Waste Numbers and enter it in column A. On the same line complete columns B, C and D by estimating the total annual quantity of the waste and describing all the processes to be used to treat, store, and/or dispose of the waste. 2. In column A of the next line enter the other EPA Hazardous Waste Number that can be used to describe the waste. In column D(2) on that line enter "included with above" and make no other entries on that line. 3. Repeat step 2 for each EPA Hazardous Waste Number that can be used to describe the hazardous waste. EXA MPLE FOR COMPLETING ITEM XIV (shown in line numbers X-1, X-2, X-3, and X-4 below) - A facility will treat and dispose of an estimated 900 pounds per year of chrome shavings from leather tanning and finishing operation. In addition, the facility will treat and dispose of three non-listed wastes. Two wastes are corrosive only and there will be an estimated 200 pounds per year of each waste. The other waste is corrosive and ignitable and there will be an estimated 100 pounds per year of that waste. Treatment will be in an incinerator and disposal will be in a landfill. Line Number X X X X 1 2 3 4 A. EPA HAZARD WASTE NO. (Enter code) K D D D 0 0 0 0 5 0 0 0 4 2 1 2 B. ESTIMATED ANNUAL QUANTITY OF WASTE 900 400 100 C. UNITOF MEASURE (Enter code) P P P D. PROCESS (1) PROCESS CODES (Enter) T T T 0 0 0 3 3 3 D D D 8 8 8 0 0 0 (2) PROCESS DESCRIPTION (If a code is not entered in D(1)) Included With Above EPA Form 8700-23 (Rev. XX/XX/99) -5of7- ------- Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT EPA ID Number (Enter from page 1) Secondary ID Number (Enter from page 1) \ \ \ \ \ \ \ XIV. Description of Hazardous Wastes (Continued; use additional sheets as necessary) ^^^S^^^^^^^^^^^^f^fj^^j^ Line Number 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 A. EPA Hazardous Waste No. (Enter code) B. Estimated Annual Quantity of Waste C. Unit of Measure (Enter code) D. PROCESSES (1) PROCESS CODES (Enter code) (2) PROCESS DESCRIPTION (If a code is not entered in D(1)) EPA Form 8700-23 (Rev. XX/XX/99) -6of7- ------- Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT EPA ID Number (Enter from page 1) Secondary ID Number (Enter from page 1) Attach to this application a topographic map, or other equivalent map, of the area extending to at least one mile beyond property boundaries. The map must show the outline of the facility, the location of each of its existing and proposed intake and discharge structures, each of its hazardous waste treatment, storage, or disposal facilities, and each well where it injects fluids underground. Include all springs, rivers and other surface water bodies in this map area. See instructions for precise requirements. XVI. Facility Drawing XVII. Photographs All existing facilities must include a scale drawing of the facility (See instructions for more detail). All existing facilities must include photographs (aerial or ground-level) that clearly delineate all existing structures; existing storage, treatment and disposal areas; and sites of future storage, treatment or disposal areas (see instructions for more detail). XVIII. Certification(s) / 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 qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible forgathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete, lam aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. OwnerSignature Date Signed Name and Official Title (Type or print) OwnerSignature Date Signed Name and Official Title (Type or print) Operator Signature Date Signed Name and Official Title (Type or print) Operator Signature Date Signed Name and Official Title (Type or print) XIX. Comments Note: Mail completed form to the appropriate EPA Regional or State Office. (Refer to instructions for more information) EPA Form 8700-23 (Rev. XX/XX/99) -7of7- ------- Please print or type with ELITE type (12 characters per inch) in the unshaded areas only Form Approved, OMB No. 2050-0034 Expires XX/XX/02 GSA No. 0248-EPA-OT EPA ID Number (Enter from page D Secondary ID Number (Enter from page 1) I I I II I I I I I I XIV. Description of Hazardous Wastes (Continued; Additional Sheet) ^jH^B^^^MMB^^^^^^^^^M||^^^^^B Line Number A. EPA Hazardous Waste No. (Enter code) B. Estimated Annual Quantity of Waste C, Unit of Measure (Enter code) E. PROCESSES (1) PROCESS CODES (Enter code) (2) PROCESS DESCRIPTION (If a code is not entered in E(1)) EPA Form 8700-23 (Rev. XX/XX/99) ------- |