OMB#
2010­
0032
Approval
Expires
8/
31/
06
United
States
Environmental
Protection
Agency
National
Environmental
Performance
Track
Program
Performance
Track
Facility
Annual
Report
for
accumulation
of
Hazardous
Waste
up
to
180
days
(
or
270
days
if
applicable)

1.
Name,
Address,
EPA
ID#
Facility
Name
EPA
ID
Number
|__|__|__|__|__|__|__|__|__|__|__|__|

Street
Address:

City:

State:

Zip
Code
2.
Total
quantity
of
waste
Total
quantity
of
each
hazardous
waste
generated
at
the
facility
that
has
been
managed
in
the
previous
12
months
according
to
extended
accumulation
time
periods
3.
Hazardous
waste
information
For
the
previous
year:

How
many
shipments
of
waste
were
sent
offsite?

What
types
of
facilities
was
the
waste
sent
to?

How
was
the
waste
managed
at
the
facilities?
Recycling,
treatment,
storage,
disposal,
other
(
specify)?

Describe
what
changes
in
on­
site
or
off­
site
management
of
hazardous
waste
have
occurred?

4.
Information
about
spills
Were
there
any
spills
or
accidents
of
hazardous
waste
at
extended
accumulation
units
at
the
facility,
or
during
off­
site
transport?

5.
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.
