January 2, 2015 TO: HAZARDOUS WASTE GENERATORS

January 2, 2015
TO:
HAZARDOUS WASTE GENERATORS
FROM:
MARK HALL
HAZARDOUS MATERIALS SECTION SUPERVISOR
SUBJECT:
ANNUAL LARGE OR SMALL QUANTITY HAZARDOUS WASTE GENERATOR REPORT
FOR CALENDAR YEAR 2014
The Administrative Rules of Montana (ARM) require large and small quantity hazardous waste generators
file an annual report by March 1 for the previous calendar year's activities (i.e. calendar year 2014 report is
due no later than March 1, 2015).
Enclosed are the forms and instructions for completing your annual hazardous waste report for calendar
year 2014. Complete all sections that relate to your hazardous waste activities. Make any changes or
additions to the forms in the shaded areas. These forms, in Word and Adobe (PDF) format, are also located
on the Department of Environmental Quality (DEQ), Hazardous Waste Program’s website at:
http://deq.mt.gov/hazwaste/hazformsreport.mcpx
New Instruction – If you wish to change your registered status, please state the new status and why in the
Comments section on Part Two.
If you opt for electronic submission, please send your completed report in Word format to DEQ
[email protected].
The report must be submitted to this office by March 1, 2015. You may be subject to enforcement action
if you do not file by that date. Please mail or email the report to:
Waste and Underground Tank Management Bureau
Hazardous Waste Program
P.O. Box 200901 – mail
1520 East Sixth Ave – FedEx or United Parcel Services
Helena, MT 59620-0901
DEQ HAZARDOUS WASTE SECTION ([email protected])
An invoice for the assessment of the annual hazardous waste registration fees will be sent the first of May
2015.
If you have any questions, or encounter difficulties in completing the report, please contact: Cory Mikita
(CEM), (406) 444-1435 or Judy Watkins (JAW), (406) 444-5852 of the Hazardous Waste Program
Regulatory Unit. Your DEQ contact is listed in Part One, Section II (DEQ Contact) of your 2014 Hazardous
Waste Report.
Steve Bullock, Governor I Tom Livers, Director I P.O. Box 200901 I Helena, MT 59620-0901 I (406) 444-2544 I www.deq.mt.gov
(Make any corrections or additions in the shaded areas.)
2014 MONTANA LARGE OR SMALL QUANTITY HAZARDOUS WASTE GENERATOR REPORT
This report is for the calendar year ending December 31, 2014. Please read all instructions in the 2013 Hazardous Waste Report Instructions Booklet before
making any entries on the form. PLEASE TYPE / PRINT
PART ONE
Generator Information
II
GENERATOR STATUS
DURING 2014
See instructions for generator
status definitions and check
correct box.
EPA ID # / DEQ CONTACT
III
SITE NAME
IV
SITE
LOCATION
ADDRESS
I
Actual Generator Status
during 2014
Page 1 of ____
State Use Only
Inspector:
RCRAInfo
 NRR
CEDARS
Mailing Date: January 2, 2015
Large Generator
Non-Handler
Small Generator
Out of Business
Conditionally Exempt Generator
Short Term/One-Time
2014 REGISTERED
STATUS
Address
City
State
MT
Zip
CONTACT PERSON
First
| MI | Last
TITLE
TELEPHONE
V
EXTENSION
Address
MAILING
ADDRESS
City
State
Zip
FAX NUMBER
EMAIL
ALTERNATE CONTACT
First
| MI | Last
VI
TITLE
TELEPHONE
EXTENSION
EMAIL
VII
SITE LEGAL OWNER
VIII
CERTIFICATION
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision according to 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 for gathering the information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. (40 CFR 270.11).
 Please Type or Print 
Name
First | MI | Last
Title
Revised 2014
Signature
Date Signed
(mm/dd/yyyy)
A blank electronic reporting form, in Word and Adobe (PDF) format, is available at the DEQ Hazardous Waste website: http://deq.mt.gov/HazWaste/hazFormsReport.mcpx
EPA ID NUMBER:
- - GENERATOR NAME:
Page __ of __
PART TWO – Waste Identification (See Instructions) (Make copies of this sheet for additional pages.)
A
Line
#
Description of Waste
B
EPA Hazardous
Waste Codes
(D001, D002…)
C
D
Amount of
Waste
Generated
Unit of Measure
E
Density
lbs/gal
sg
lbs/gal
sg
lbs/gal
sg
lbs/gal
sg
lbs/gal
sg
lbs/gal
sg
Comments
Revised 2014
Amount Shipped
Off-Site
F
G
Waste Minimization
Code (see Instructions,
page 4)
Transporter (T)
EPA ID Number (#) & Name
Receiving Facility (R)
EPA ID Number (#) & Name
T#
T Name
R#
R Name
T#
T Name
R#
R Name
T#
T Name
R#
R Name
T#
T Name
R#
R Name
T#
T Name
R#
R Name
T#
T Name
R#
R Name