OMB#
2010­
0032
Approval
Expires
8/
31/
06
United
States
Environmental
Protection
Agency
National
Environmental
Performance
Track
Program
Facility
Notification:
Intent
to
Accumulate
Hazardous
Waste
up
to
180
days
(
or
270
days
if
applicable)

1.
Name,
EPA
ID#,
date
to
begin
accumulation
Facility
Name
EPA
ID
Number
|__|__|__|__|__|__|__|__|__|__|__|__|

Street
Address:

City:

State:

Zip
Code
(
Facility
Name)
will
begin
accumulation
of
Hazardous
Waste
on
(
insert
date)
in
accordance
with
40
CFR
262.34j
2.
Types
of
waste
and
types
of
units
for
storage
List
types
of
hazardous
waste
that
will
be
accumulated
at
this
site
List
of
names
of
units
used
for
accumulation:

3.
Facility
changes
(
Facility
Name)
has
made
all
changes
to
its
operations,
procedures,
and
equipment,
that
is
necessary
to
accommodate
extended
time
periods
for
accumulating
hazardous
wastes.
Such
changes
include
emergency
preparedness
and
equipment
needed
for
emergency
preparedness.

4.
Certification
for
generators
storing
up
to
270
days
For
facilities
who
are
accumulating
hazardous
waste
up
to
270
days
only:
I
certify
that
a
facility
that
is
RCRA
permitted,
or
operating
under
interim
status,
is
not
available
within
200
miles
of
(
Insert
facility
name).

Certification.
I
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
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.

_________________________________________
_____________________
Signature
Date
EPA
Form
XXX­
X
(
8­
2004)

The
annual
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
3.4
hours
per
year
for
each
facility.
Send
comments
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
through
the
use
of
automated
collection
techniques
to
the
Director,
Collection
Strategies
Division,
U.
S.
Environmental
Protection
Agency
(
2822T),
1200
Pennsylvania
Ave.,
NW,
Washington,
D.
C.
20460.
Include
the
OMB
control
number
in
any
correspondence.
Do
not
send
the
completed
form
to
this
address.
