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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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