
y`





1. Submitter Information


2. Facility EPA ID Number

3. Facility Name and Address


4. Reporting Calendar Year

5. Facility Type

6. Technology Type (all 
that apply)



7. PCB Waste in Storage at the Beginning of the Calendar Year



8. PCB Waste Received and Generated During the Calendar Year
                                       
                                       
                                       
                 United States Environmental Protection Agency
                               PCB ANNUAL REPORT
                             40 CFR 761.180(b)(3)
                                       

Name: _____________________________  Job Title: _____________________________ Phone Number: _____________________  Email Address: ________________________



EPA ID Number: ______________________________



Name: ___________________________________________________________________
Street Address: ____________________________________________________________
City: ___________________________   State: _______    Zip Code: _________________


Calendar Year: _____________


     Commercial Storer         Disposer       Both


  Incinerator       Chemical Dechlorination       Chemical Waste Landfill
  High Efficiency Boiler       Scrap Metal Recovery Oven                                           Fluorescent Light Ballast Recycler     PCB Electrical Cable Processing for Metal Recovery     PCB Transformer Decommissioning    Pipeline and Compressor Systems Decontamination      Other__________________________________________________________________



                     Large Low and High Voltage Capacitors
                              Article Containers
                                 Transformers
                                     Bulk
                                  Containers
                                     Other
Weight (kg)
                                       
                                       
                                       
                                       
                                       
                                       
Total Number
                                       
                                       
                                       
                                      N/A
                                       
                                       
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(1)

                     Large Low and High Voltage Capacitors
                              Article Containers
                                 Transformers

                                   Received
                                   Generated
                                   Received
                                   Generated
                                   Received
                                   Generated
Weight (kg)
                                       
                                       
                                       
                                       
                                       
                                       
Total Number
                                       
                                       
                                       
                                       
                                       
                                       











9. PCB Waste Transferred to Another Facility During the Calendar Year




10. PCB Waste Disposed of at the Facility During the Calendar Year




11. PCB Waste in Storage at the Facility at the end of the Calendar Year




Additional
Information


(2)

                                     Bulk
                                  Containers
                                     Other

                                   Received
                                   Generated
                                   Received
                                   Generated
                                   Received
                                   Generated
Weight (kg)
                                       
                                       
                                       
                                       
                                       
                                       
Total Number
                                      N/A
                                      N/A
                                       
                                       
                                       
                                       



                     Large Low and High Voltage Capacitors
                              Article Containers
                                 Transformers
                                     Bulk
                                  Containers
                                     Other
Weight (kg)
                                       
                                       
                                       
                                       
                                       
                                       
Total Number
                                       
                                       
                                       
                                      N/A
                                       
                                       



                     Large Low and High Voltage Capacitors
                              Article Containers
                                 Transformers
                                     Bulk
                                  Containers
                                     Other
Weight (kg)
                                       
                                       
                                       
                                       
                                       
                                       
Total Number
                                       
                                       
                                       
                                      N/A
                                       
                                       



                     Large Low and High Voltage Capacitors
                              Article Containers
                                 Transformers
                                     Bulk
                                  Containers
                                     Other
Weight (kg)
                                       
                                       
                                       
                                       
                                       
                                       
Total Number
                                       
                                       
                                       
                                      N/A
                                       
                                       


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EPA Form XXXX
EPA Form XXXX

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INSTRUCTIONS FOR FILLING OUT THE PCB ANNUAL REPORT FORM
______________________________________________________________________________
Who Must Use this Form

Owners or operators of facilities who dispose of or commercially store PCB waste are required to submit a PCB Annual Report for that calendar year (40 CFR 761.180). Owners or operators of facilities who dispose of or commercially store PCB waste are required to use this form to submit the information. 

Purpose of this Form

This form is made available to owners and operators of facilities who dispose of or commercially store PCB waste. Such facilities are required to submit information on PCB waste in storage at the beginning of the calendar year, received, generated, transferred, and disposed during the calendar year, and in storage at the end of the calendar year. For more information on the reporting requirements, please refer to 40 CFR 761.180.

Where to Send this Form

Owners or operators of facilities who dispose of or commercially store PCB waste should print the completed form, with any applicable attachments, and mail or email it to the EPA Headquarters Office at 1200 Pennsylvania Ave NW MC: 5303P, Washington DC 20460.

How to Fill out this Form

Please pay attention to the following notes when completing this form:

 Please fill out all sections of the form, even if they are not applicable to your facility. For example, if your facility did not dispose of any PCB waste, enter "0" for all items in section number 10 instead of leaving those fields blank. Please note that negative values are not valid. 

 Enter both received and generated values for Item 8, not one combined value. 
      
 Refer to Attachment A for definitions of PCB waste categories.

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If you have any questions regarding this form, please contact your EPA Regional Coordinator or EPA Headquarters.
                    ATTACHMENT A TO PCB ANNUAL REPORT FORM
               Select Definitions of PCB Waste from 40 CFR 761.3
______________________________________________________________________________
Large high voltage capacitor means a capacitor which contains 1.36 kg (3 lbs.) or more of dielectric fluid and which operates at 2,000 volts (AC or DC.) or above.

Large low voltage capacitor means a capacitor which contains 1.36 kg (3 lbs.) or more of dielectric fluid and which operates below 2,000 volts (AC or DC).

PCB Article Container means any package, can, bottle, bag, barrel, drum, tank, or other device used to contain PCB Articles or PCB Equipment, and whose surface(s) has not been in direct contact with PCBs.

      PCB Article means any manufactured article, other than a PCB Container, that contains PCBs and whose surface(s) has been in direct contact with PCBs. "PCB Article" includes capacitors, transformers, electric motors, pumps, pipes and any other manufactured item (1) which is formed to a specific shape or design during manufacture, (2) which has end use function(s) dependent in whole or in part upon its shape or design during end use, and (3) which has either no change of chemical composition during its end use or only those changes of composition which have no commercial purpose separate from that of the PCB Article.

      PCB Equipment means any manufactured item, other than a PCB Container or a PCB Article Container, which contains a PCB Article or other PCB Equipment, and includes microwave ovens, electronic equipment, and fluorescent light ballasts and fixtures.

PCB Transformer means any transformer that contains >=500 ppm PCBs. For PCB concentration assumptions applicable to transformers containing 1.36 kilograms (3 lbs.) or more of fluid other than mineral oil, see § 761.2. For provisions permitting reclassification of electrical equipment, including PCB Transformers, containing >=500 ppm PCBs to PCB-Contaminated Electrical Equipment, see § 761.30(a) and (h).

PCB Container means any package, can, bottle, bag, barrel, drum, tank, or other device that contains PCBs or PCB Articles and whose surface(s) has been in direct contact with PCBs.

Bulk PCB Waste means waste that is classified as either PCB Remediation Waste or PCB Bulk Product Waste (see those definitions below). 

PCB Bulk Product Waste means waste derived from manufactured products containing PCBs in a non-liquid state, at any concentration where the concentration at the time of designation for disposal was >=50 ppm PCBs. PCB bulk product waste does not include PCBs or PCB Items regulated for disposal under §§ 761.60(a) through (c), 761.61, 761.63, or 761.64. PCB bulk product waste includes, but is not limited to:
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      (1) Non-liquid bulk wastes or debris from the demolition of buildings and other manmade structures manufactured, coated, or serviced with PCBs. PCB bulk product waste does not include debris from the demolition of buildings or other man-made structures that is contaminated by spills from regulated PCBs which have not been disposed of, decontaminated, or otherwise cleaned up in accordance with subpart D of this part.
      
      (2) PCB-containing wastes from the shredding of automobiles, household appliances, or industrial appliances.
      
      (3) Plastics (such as plastic insulation from wire or cable; radio, television and computer casings; vehicle parts; or furniture laminates); preformed or molded rubber parts and components; applied dried paints, varnishes, waxes or other similar coatings or sealants; caulking; adhesives; paper; Galbestos; sound deadening or other types of insulation; and felt or fabric products such as gaskets.
      
      (4) Fluorescent light ballasts containing PCBs in the potting material.

PCB Remediation Waste means waste containing PCBs as a result of a spill, release, or other unauthorized disposal, at the following concentrations: 

 Materials disposed of prior to April 18, 1978, that are currently at concentrations >= 50 ppm PCBs, regardless of the concentration of the original spill; 
 Materials which are currently at any volume or concentration where the original source was >= 500 ppm PCBs beginning on April 18, 1978, or >= 50 ppm PCBs beginning on July 2, 1979; and 
 Materials which are currently at any concentration if the PCBs are spilled or released from a source not authorized for use under this part. 
      
   PCB remediation waste means soil, rags, and other debris generated as a result of any PCB spill cleanup, including, but not limited to: 
   
 Environmental media containing PCBs, such as soil and gravel; dredged materials, such as sediments, settled sediment fines, and aqueous decantate from sediment. 
 Sewage sludge containing < 50 ppm PCBs and not in use according to § 761.20(a)(4); PCB sewage sludge; commercial or industrial sludge contaminated as the result of a spill of PCBs including sludges located in or removed from any pollution control device; aqueous decantate from an industrial sludge. 
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Buildings and other man-made structures (such as concrete floors, wood floors, or walls contaminated from a leaking PCB or PCB-Contaminated Transformer), porous surfaces, and non-porous surfaces.  
                                               United States
    USEPA	Environmental Protection Agency
                                            Washington, DC 20460

      Form Approved OMB No. 2070-0112
                      Notification	of	PCB	Activity
   For more information, contact ORCRPCBs@epa.gov

 Return To:
           Document Control Officer (5305P) Office of Solid Waste
           U.S. Environmental Protection Agency 1200 Pennsylvania Ave., N.W. Washington, DC 20460-0001
              For Official Use Only


1. Name of Facility
 Name of Owner Facility
 2. EPA Identification Number (if already assigned under RCRA)
3. Facility Mailing Address (Street or PO Box, City, State, & Zip Code)
 4. Location of Facility (No. Street, City, State, & Zip Code)
5. Installation Contact (Name and Title)
 Type of PCB Activity (Mark `X' in appropriate box. See Instructions.)
   A. Generator w/on-site storage facility	B. Storer (Commercial)
   C. Transporter	D. R&D/Treatability
                          E. Approved Disposer	F. Scrap Metal Recovery Oven/Smelter, High Efficiency Boilers
Telephone Number (Area Code and Number) and Email Address 

  7. Certification

  Under civil and criminal penalties of law for the making or submission of false or fraudulent statements or representations (18 U.S.C. 1001 and 15 U.S.C. 2615), I certify that the information contained in or accompanying this document is true, accurate, and complete. As to the identified section(s) of this document for which I cannot personally verify truth and accuracy, I certify as a company official having supervisory responsibility for the persons who, acting under my direct instructions, made the verification that this information is true, accurate, and complete.
Signature
 Name and Official Title (Type of Print)
Date Signed
                                Paperwork Reduction Act Notice
   The annual public burden for this collection of information is estimated to average 0.6 hours per response. This estimate includes time for reading instructions, searching existing data sources, gathering and maintaining the needed data, and completing and reviewing collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to: Director, Collection Strategies Division,
   U.S. Environmental Protection Agency (mail code 2822), 1200 Pennsylvania Ave., N.W., Washington, D.C. 20460-0001. Include the OMB number identified above in any correspondence.
   Do not send the completed form to this address. The actual information or form should be submitted in accordance with the instructions accompanying the form, or as specified in the corresponding regulations.
 EPA Form 7710-53 (Rev. MM/YY)
 Previous editions are obsolete.
           Item-by-Item Instructions for Completing EPA Form 7710-53
 
 Return completed form to:
 Document Control Officer (5305P) 
ATTN: PCB Notification
 Office of Resource Conservation and Recovery
 U.S. Environmental Protection Agency 
 1200 Pennsylvania Ave., N.W. Washington, DC 20460-0001
 
 For more information, contact ORCRPCBs@epa.gov
 No information on the form may be claimed confidential.

 Type or print in black ink all items, except Item VII, "Certification." If you must use additional sheets, indicate clearly the number of the item on the form to which the information on the separate sheet applies.

 Item 1 -- Name of facility: Enter the name of the facility and the name of the owner of the facility.

 Item 2 -- EPA identification number (if already assigned under RCRA): Enter the identification number the facility was assigned under the RCRA hazardous waste notification regulations. If no identification number has been assigned, leave this space blank. A notifier may use their RCRA Identification number prior to receipt of written verification from EPA once they have confirmed that EPA is in receipt of their PCB notification form. Confirmation of receipt of the form may be accomplished by submitting it through the U.S. mail -- return receipt requested, telephoning to confirm receipt of mail or facsimile, commercial overnight carrier's delivery verification processes, or any other manner in which the submitter can demonstrate in that the form was received by EPA Headquarters.

 Items 3 and 4 -- Facility mailing address and location: Complete Items III and IV. Please note that the address you give in Item IV, "Location of Facility," must be a physical address, not a post office box or route number. If the mailing address and physical location are the same, you may enter "Same" in Item IV. If the facility is a mobile incinerator, you may enter "mobile" in Item IV, and provide the mailing address for the installation contact in Item III.

 Item 5 -- Installation contact: Enter the name, title, email address and business telephone number of the person who should be contacted regarding information submitted on this form.

 Item 6 -- Type of PCB activity: Mark the appropriate box(es) to show which PCB activities are taking place at this facility.

 Generator with on-site storage facility: You are a generator with an on-site storage facility under this notification requirement if you are a user, owner, or processor of PCBs or PCB items and you maintain your own storage facilities subject to 40 CFR 761.65(b) or (c)(7) for PCBs. If you are a generator with an on-site storage facility, mark an "X" in this box.

 Commercial Storer: You are a commercial storer if you own or operate a storage facility which is subject to the storage facility standards of 40 CFR 761.65(b) or (c)(7), and which engages in off-site storage activities involving the PCB wastes generated by others. Most commercial storers of PCB waste perform waste storage services in exchange for a fee or other compensation, but the receipt of compensation is not necessary for your storage facility to qualify as a commercial storer of PCB wastes generated by others. See definition of commercial storer in 40 CFR 761.3. If you are a commercial storer, mark an "X" in this box.

        Transporter: If you move PCBs by air, rail, highway, or water, then mark an "X" in this box.

 R&D/Treatability: If you are engaged in conducting R&D into PCB disposal technologies and cannot accept waste on a commercial scale, mark an "X" in this box. You should also check this box if you conduct treatability studies even though you may have marked the "Approved Disposer" box.

 Approved Disposer: If you currently hold a valid EPA permit to dispose of PCBs in concentrations exceeding 50 ppm in a landfill, through alternative technology or incineration, mark an "X" in this box.

 Scrap Metal Recovery Oven/Smelter, High Efficiency Boilers: If you operate a device to dispose of PCBs, or if you dispose of PCBs in compliance with Section 761.71 (i.e., high efficiency boilers) or Section 761.72 (i.e., scrap metal recovery oven/smelter), mark an "X" in this box.

 Item 7 -- Certification: This certification must be signed by the owner, operator, or an authorized representative of the facility. An "authorized representative" is a person responsible for the overall operation of the facility (i.e., a plant manager or superintendent, or a person of equal responsibility). All notifications must include this certification to be complete.
EPA Form 7710-53 Reverse (Rev. 3/08)
