New Forms and Required Fields Guide...15. CN-1044 UO-AR USED OIL ANNUAL REPORT 14. UO-D 15. UO-AR 8. TSD-FDS Note: Only one HN-CS form is required to be returned with each annual report

Changes to Tennessee's Annual Hazardous Waste Report Forms

New Forms

(Please Read)

Required Fields Guideand

CRP

=REQUIRED

REQUIRED

=CONDITIONALLY

SUGP =SUGGESTED

*

Fields Are Marked As Follows:

Changes affect:Hazardous Waste Transporters

Hazardous Waste Generators

Hazardous Waste TSD's

Hazardous Waste Transfer Facilities

Used Oil Reporting

Universal Waste Reporting

New Registrations and Existing Filers

*P

Changes to Tennessee's Annual Hazardous Waste Report Forms New Forms and Required Fields Guide (continued)

Definitions:

CRP

*=REQUIRED

REQUIRED

=CONDITIONALLY

SUGP =SUGGESTED


-Page 2-

*=REQUIRED

Fields so marked must be filled in. To leave a REQUIRED field blank means a delay in processing.

For some this will mean a delay in the issuance of a permit (transporters).

If a REQUIRED field is left blank, auditors must call or return the packets for completion.

SOLUTION: Make certain you double check your forms. Write legibly. Fill in all REQUIRED Fields.

Fields so marked must be filled in depending on the data you provided in another field. For instance,

if your business is company owned (you checked COMPANY beside BUSINESS OWNER - SECTION 4),

you must fill in the CORPORATE OWNER NAME in section 4. However, if your business is owned by

an individual (you checked INDIVIDUAL beside BUSINESS OWNER - SECTION 4), you must enter the

LAST NAME, FIRST NAME and TITLE in Section 4. If you leave a CONDITIONALLY REQUIRED field

blank - and you were required to provide data for that field- your packet must be returned or you

must be contacted to verify the data causing a serious delay in processing.

For some this will mean a delay in the issuance of a permit (transporters).

SOLUTION: Be aware that some fields may be related to responses you made in previous fields. Make

certain you double check your forms. Write legibly. Fill in all REQUIRED Fields.

CRP =CONDITIONALLY REQUIRED

SUGP =SUGGESTED

Fields so marked are NOT REQUIRED. However, taking the time to provide a response may greatly

improve our data quality.

The State of Tennessee's Department of Environment and Conservation is preparing a new computer

processing system for all who must file an Annual Report for Hazardous Waste. We need your help!

The data you provide on the new forms for this year MUST FOLLOW NEW guidelines. The data you

provide will build the structure for the future! Soon, an electronic version of your Annual Report will

replace the manual forms. That's why your data must be accurate this year. Just think how easy it will

be to make changes to your information and file your reports on-line! Help us get there.

Be Accurate!

We Need Your Help!

Double Check Your Forms!

Write Legibly!

P

P

*

Changes to Tennessee's Annual Hazardous Waste Report Forms and how they are to be submitted New Forms and Required Fields Guide (continued)*

-Page 3-

Short Name

We Need Your Help!

Required Forms for Annual Reports

Form ID Form Title Special Use

1. HN-CSCN-1442 UNIFIED CERTIFICATION AND COVER SHEET SINGLE CERTIFICATION FOR PACKET

2. HN-HCN-1447 HAZARDOUS WASTE REGISTRATION AND NOTIFICATION

3. HN-H CONTACTSCN-1445 HAZARDOUS WASTE CONTACT NOTIFICATION

4. HN-EACN-1446 HAZARDOUS WASTE ENVIRONMENTAL ACTIVITY NOTIFICATION

5. NFCN-1443 HAZARDOUS WASTE NOTIFICATION FEES

6. TRFDSCN-0783 HAZARDOUS WASTE TRANSPORTER FEE DETERMINATION

7. G-FDSCN-0906 ANNUAL HAZARDOUS WASTE GENERATION FEE DETERMINATION

8. TSD-FDSCN-0912 TSDR ANNUAL FEE SHEET

9. WSRCN-0773 HAZARDOUS WASTE STREAM REPORT

10. OSRCN-0779 HAZARDOUS WASTE OFFSITE SHIPPING

11. TWRCN-0905 TREATMENT, STORAGE, DISPOSAL AND RECYCLING OFFSITE WASTE RECEIVING

12. TPACN-0876 TREATMENT, STORAGE, DISPOSAL AND RECYCLING PERMITTED ACTIVITY

13. HN-CCN-1444 HAZARDOUS WASTE SITE CLOSURE NOTIFICATION

14. UO-DCN-1303 USED OIL TRANSPORTER CERTIFICATION

CLOSURE, BUSINESS INTERRUPTION

GENERATORS

TRANSPORTERS

TRANSFER FACILITIES

TSDs

USED OIL

UNIVERSAL WASTE

1. HN-CS

1. HN-CS

1. HN-CS

1. HN-CS

1. HN-CS

1. HN-CS

2. HN-H

2. HN-H

2. HN-H

2. HN-H

2. HN-H

2. HN-H

3. HN-H CONTACTS

3. HN-H CONTACTS

3. HN-H CONTACTS

3. HN-H CONTACTS

3. HN-H CONTACTS

3. HN-H CONTACTS

4. HN-EA

4. HN-EA

4. HN-EA

4. HN-EA

4. HN-EA

4. HN-EA

5. NF

5. NF

5. NF

6. TRFDS

7. G-FDS

15. UO-ARCN-1044 USED OIL ANNUAL REPORT

14. UO-D 15. UO-AR

8. TSD-FDS

Note: Only one HN-CS form is required to be returned with each annual report packet

NEW EPA ID; ADD WASTESTREAMS

USED OIL TRANSPORTERS ONLY

NEW FILERS 1. HN-CS 2. HN-H 3. HN-H CONTACTS 4. HN-EA 5. NF

9. WSR 10. OSR

11. TWR 12. TPA

9. WSR (HW GENERATION)(GENERATORS, HW TRANSFER, USED OIL,

UNIVERSAL WASTE, TSDs)

NEW FILERS(HW TRANSPORTERS)

1. HN-CS 2. HN-H 3. HN-H CONTACTS 4. HN-EA 6. TRFDS

FOR RECEIVED WASTE

PERMITTED ACTIVITY

AVAILABLE ON-LINE

AVAILABLE ON-LINE

OWNER CHANGE 1. HN-CS 2. HN-H 3. HN-H CONTACTS 5. NF - NOT FOR TRANSPORTERS

(GENERATORS, HW TRANSFER, USED OIL,

UNIVERSAL WASTE, TSDs)6. TRFDS - TRANSPORTERS

LOCATION CHANGE 1. HN-CS 2. HN-H 3. HN-H CONTACTS 5. NF - NOT FOR TRANSPORTERS

(GENERATORS, HW TRANSFER, USED OIL,

UNIVERSAL WASTE, TSDs)6. TRFDS - TRANSPORTERS

SITE CLOSURE or BUSINESS

INTERRUPTION

1. HN-CS 2. HN-H 13. HN-C

CHANGE IN GENERATOR

STATUSCHANGES IN AMOUNT GENERATED MUST BE REFLECTED ON FORM WSR1. HN-CS 4. HN-EA 9. WSR

CHECK "INFORMATION UPDATE" ON FORM WSR

AMOUNTS WILL BE VERIFIED WITH GEN STATUS YOU CHECK ON FORM HN-EA

9. WSR (HW GENERATION IF WS TO BE CLOSED)

Note: For all forms, pay close attention to the instructions printed on the actual form.

Pay particular attention for instructions on the payment of fees and addresses where the

fees must be mailed.

HN - CS

RDA 2203

UNIFIED CERTIFICATION AND COVER SHEET

ATTACH THIS COVER SHEET TO ALL REQUESTS, PACKETS, DOCUMENTS OR FORMS

INFORMATION UPDATES

CONTACT PERSON

ADD ENVIRONMENTAL ACTIVITY

ADD WASTE STREAM(S)

CLOSE A WASTE STREAM

UPDATE WASTE STREAM INFORMATION

HAZ WASTE GENERATOR ANNUAL REPORT

CORRECTED

CURRENT LOCATION ADDRESS - NO P.O. BOX NUMBERS

E-MAIL

TN COUNTY

LOCATION CITY STATE ZIP

REGULATORY INTERPRETATION

SEND MAIL TO: LAST NAME FIRST NAME MI TITLE / DEPARTMENT

STREET ADDRESS CITY STATE ZIP

LATE

USED OIL ANNUAL REPORT

HW TRANSFER FACILITY ANNUAL FEES

UNIVERSAL WASTE ANNUAL FEES

SUPPLYING REQUESTED DOCUMENT(S)

PRINTED FORMS

SPECIAL ASSISTANCE

CHECK IF FEE PAYMENT ATTACHED

REQUEST FOR REFUND

RESPONSE TO ENFORCEMENT

NEW REGISTRANTS - SUBMIT THESE FORMS:

HN-CS

HN-H

NF

HN-EA

WSR

CLOSING OR BUSINESS, INTERRUPTION, ETC

USED OIL ANNUAL REPORT (CORRECTED)

USED OIL ANNUAL REPORT (LATE)BUSINESS OPERATIONAL STATUS

OTHER ATTACHMENT(S)

USED OIL ANNUAL FEES

(DIRECTIONS IF NECESSARY)

(THIS FORM)

REGISTRATION / NOTIFICATION

FEES- TRANSPORTERS USE FORM TR-FDS

ENVIRONMENTAL ACTIVITY

FOR EACH WASTE STREAM

ENTER YOUR EPA ID

ENTER YOUR SITE, BUSINESS, OR INSTALLATION NAME

APPLYING FOR AN APPLYING FOR A USED

PHONE FAX

USED OIL REGISTRATION NUMBER

NOT

REGISTERED APPLYING FOR A HAZARDOUS

HAZARDOUS WASTE

TRANSFER

EPA ID

NUMBER

ENTER EPA ID OF SITE YOU ARE MOVING TO

FD

052114

I certify under penalty of law that this document and all attachments were prepared by me, or under my direction or supervision. The

submitted information 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. As specified in Tennessee Code Annotated

Section 39-16-702(a)(4), this declaration is made under penalty of perjury.

CERTIFICATION REQUIRED

SIGNATURE OF AUTHORIZED REPRESENTATIVE

DATE

TITLE

PRINTED NAME

3. LOCATION

CHANGE

6.

1.

2.REGISTERED

SITE

7.

REPORTS / FEES: SPECIAL REQUESTS:

OTHER:

END ENVIRONMENTAL ACTIVITY

SITE OR BUSINESS ASSOCIATED WITH EPA ID

CONTINUED

OWNER

CHANGE4. NEW CHANGE OWNER

ADDRESS CHANGED BY 911 EMERGENCY SYSTEM

REZONING / ANNEXATION

ORIGINAL LOCATION ADDRESS IS INCORRECT

BUSINESS PHYSICALLY MOVED TO A NEW LOCATION

NAME

CHANGE5. NEW UPDATE

UPDATE OTHER OWNER INFORMATION

NEW UPDATE

TSDF ANNUAL FEES

TSDF APPLICATION FEES

ATTACHMENTS AND OTHER REQUESTS

ADDITIONAL INFORMATION OR COMMENTS

Renew TRANSPORTER PERMIT

u

ADDITIONAL(CESQG, D-I-Y USED OIL,

UWASTE ETC SEE PG 2)

(NON-FEE)EPA ID NUMBER OIL NUMBER WASTE TRANSPORTER PERMIT CATEGORIES

CN-1442

** * * **

* * *

* ** *

CRP

=REQUIRED

REQUIRED

=CONDITIONALLY

SUGP =SUGGESTED


PCR if new, not required PCR if new, not required

*

PSUG

PCR if in Tennessee

** *

*

P P

P

P

Department of Environment and Conservation

Division of Solid Waste Management

State of Tennessee

William R. Snodgrass Tennessee Tower

Nashville, TN 37243

312 Rosa L. Parks Avenue, 14th Floor

LOG ID CODE STAFF INITIALS ( ) NEWLY ASSIGNED ( ) TRANSFERRED EPA ID NUMBERDATE GIA CUSTOMER #

TDEC USE ONLY

UOP NUMBERFAC ID

FOLLOWING IS A LIST OF ADDITIONAL FORMS REQUIRED FOR CERTAIN NOTIFICATIONS

ENVIRONMENTAL ACTIVITY HN-EA

PAYMENT OF FEES NF

CLOSURE HN-C

WASTE STREAM REPORT WSR

ANNUAL GENERATOR FEES G-FDS

SHIPPING REPORT OSR

WASTE RECEIVING REPORT TWR

TSDR PERMIT ACTIVITY TPA

TSDR ANNUAL FEE FORM TSD-FDS

TSDF APPLICATION FEES TSD-APP

HAZARDOUS WASTE ENVIRONMENTAL ACTIVITY NOTIFICATION

HAZARDOUS WASTE NOTIFICATION FEES

HAZARDOUS WASTE SITE CLOSURE NOTIFICATION

HAZARDOUS WASTE STREAM REPORT

ANNUAL HAZARDOUS WASTE GENERATION FEE DETERMINATION

HAZARDOUS WASTE OFFSITE SHIPPING REPORT

TREATMENT, STORAGE, DISPOSAL and RECYCLING OFFSITE

WASTE RECEIVING

TREATMENT, STORAGE, DISPOSAL and RECYCLING PERMITTED

ACTIVITY

ANNUAL TSDF FEE DETERMINATION

HAZARDOUS WASTE TREATMENT, STORAGE, DISPOSAL

CN-0906

REGISTRATION HN-H HAZARDOUS WASTE REGISTRATION AND NOTIFICATION

CN-0773

CN-1261

CN-0779

CN-0876

CN-0905

NEW REGISTRANTS; IDENTIFYING ENVIRONMENTAL ACTIVITY AND DATES

NEW REGISTRANTS; OWNER CHANGE, ADD WASTE STREAMS; ANNUAL FEES

NEW REGISTRANTS; ALSO ANNUALLY

SITE CLOSURE NOTIFICATION

NEW REGISTRANTS; ANNUALLY AND WHEN ADDING WASTE STREAMS

ON-LINE INTERACTIVE FORM CALCULATES ANNUAL GENERATOR FEE

ANNUAL REPORT REQUIREMENT; SHIPMENTS / DESTINATIONS

ANNUAL REPORT REQUIREMENT TSDs ONLY; WASTE RECEIVED

ANNUAL REPORT REQUIREMENT TSDs ONLY; PERMITTED WASTE ACTIVITY

ANNUAL REPORT REQUIREMENT TSDs ONLY; ON-LINE FEE CALCULATION

TSDF ONLY; REVIEW AND APPLICATION FEE SHEET

CN-0912

GENERAL INFO USE THIS FORM FORM ID WHEN TO SUBMIT

FORM GUIDANCE

EPA ID SITE OR FACILITY NAME

USED OIL TRANSPORTER UO-D CN-1303USED OIL TRANSPORTER CERTIFICATION USED OIL DRIVER CERTIFICATION

USED OIL ANNUAL UO-AR CN-1044USED OIL ANNUAL REPORT ANNUAL REPORT FOR USED OIL MANAGEMENT

ABBREV

COVER SHEET HN-CS HAZARDOUS WASTE NOTIFICATION COVER SHEET EACH SUBMISSION TO TDEC (INCLUDING NEW REGISTRANTS)

CONTACT CONTINUATION HN-H HAZARDOUS WASTE CONTACT ADD OR CHANGE FORM CONTINUATION FORM TO IDENTIFY SPECIFIC ENV ACTIVITY FOR CONTACTS

FACILITY (TSDF) APPLICATION AND OTHER REVIEW FEES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

N A

N A

N A

N A

N A

N A

N A

N A

N A

N A

N A

N A

A

REQ

N A REQNOTIFICATION / REGISTRATION ANNUAL REPORT AS REQUIRED

REQ

PAGE 2 RDA 2203

HAZARDOUS WASTE GENERATOR MARCH 1

HAZARDOUS WASTE TSDF MARCH 1

ANNUAL REPORT AND FEES


DEADLINES

*HAZARDOUS WASTE TRANSFER FACILITY DEC 31

*USED OIL TRANSPORTER

*USED OIL TRANSFER FACILITY

*USED OIL PROCESSOR / RE-REFINER

*UNIVERSAL WASTE DESTINATION FACILITY

MARCH 1

MARCH 1

MARCH 1

MARCH 1

ANNUAL FEES


ANNUAL FEES


ANNUAL FEES

*HAZARDOUS WASTE TRANSPORTER DEC 31ANNUAL PERMIT RENEWAL AND FEES

G-FDS, HN-H, NF, WSR, OSR

HN-H, NF

TSD-FDS, HN-H, NF, WSR, OSR, TPA, TWR

HN-H, NF

HN-H, NF, UO-D

HN-H, NF

HN-H, NF

HN-H, NF

ENVIRONMENTAL ACTIVITY ACTION DEADLINE FORMS REQUIRED (IN ADDITION TO THIS FORM HN-CS)

FEES DUE AT TIME OF REGISTRATION; SEE FORM NF FOR DETAILS

CONTACT INFORMATION

WHERE TO MAIL DOCUMENTS AND CORRESPONDENCE WHERE TO MAIL PAYMENTS AND FEES:

MAKE PAYABLE TO: "TREASURER, STATE OF TENNESSEE"

FREQ

*

USED OIL REGISTRATION NUMBER

GENERAL REGISTRATION:

You may select ADDITIONAL CATEGORIES to register your location as a CESQG or identify certain USED OIL/UNIVERSAL WASTE related activities, etc.

There are NO REGISTRATION FEES ASSOCIATED WITH THE CHECKING OF THIS BOX.

IF YOU ARE RETURNING DOCUMENTS WITH FEES, USE THIS ADDRESS

CN-1442

PCR if new, not requiredP PCR if applicableP *


Division of Fiscal Services -

State of Tennessee


Nashville, TN 37243


Consolidated Fee SectionDepartment of Environment and Conservation


State of Tennessee


Nashville, TN 37243


HN - H

DATE OWNERSHIP BEGAN *OWNER CODE *LAND CODE

REPORT YEAR

RDA 2203

HAZARDOUS WASTE REGISTRATION AND NOTIFICATION

*Federal (F); State (S); Private (P); Indian

(I); County (C); Municipal (M); District

(D); Other (O)

# EMPLOYEES

SITE, BUSINESS, OR INSTALLATION NAME

EPA ID NUMBER (IF NEW, LEAVE BLANK) USED OIL REGISTRATION NUMBER

CONTINUED

PERMIT YEAR

SITE LOCATION ADDRESS - NO P.O. BOX NUMBERS!

E-MAILPHONE1 FAX

LAST NAME

(GIVE DIRECTIONS IF NECESSARY)

TN COUNTY

LATITUDE LONGITUDE

2. SITE NAME

CITY STATE ZIP

OWNER MAILING STREET ADDRESS

FAX EMAIL

CITY /TOWN / LOCALITY BUSINESS MAILING STREET ADDRESS

FAX EMAIL

STATE /TERRITORY ZIP / POSTAL CODE COUNTRY

CITY /TOWN / LOCALITY


4. BUSINESS OWNER

5. MAILING ADDRESS

LAST NAME FIRST NAME MI TITLE

INCOMPLETE APPLICATIONS WILL BE RETURNED

FD

052114

PHONE2

PHONE1 PHONE2

DEPARTMENT

IF CORPORATE OWNER, PROVIDE CORPORATE NAME CORPORATE REGION CORPORATE DISTRICT

TITLEFIRST NAME MI

PHONE1 PHONE2

OFFICE USE ONLY1. REGISTRATION INFORMATION

3. SITE PHYSICAL LOCATION

DATE OWNERSHIP ENDED

SEND MAIL TO THE ATTENTION OF:

INDIVIDUAL COMPANY

CN-1447

*

*

*

*

* * PCR

*PCR

PCR

if not an individual

if not a corporate

owner

* *

* * *

*

* * *

*

*

*

* *

*

P

CRP

*=REQUIRED

REQUIRED

=CONDITIONALLY

(if in Tennessee)

PCR if not a corporate

owner PCR if not a corporate

owner

P CR if applicable

SUGP =SUGGESTED

SUGP SUGP

SUGPSUGP

SUGP SUGP

P CR new registrants will not have an EPA ID

P CR


TRANSPORTERS

SUGP

CR ANNUAL RPTS

P CR if applicableSUGP

SUGP

P P

P

P

P

P

P

P

P P

P

* *

*

*



State of Tennessee


Nashville, TN 37243


NUMBER USED

TRUCKS

AIR

HIGHWAY

RAIL

WATER TRAILERS

TANKERS

BOATS, BARGES

EXPLOSIVE MATERIALS GASES

FLAMMABLE / COMBUSTIBLE LIQUIDS

FLAMMABLE SOLIDS /SPONTANEOUSLY

COMBUSTIBLE LIQUIDS

OXIDIZERS AND ORGANIC PEROXIDES

POISON LIQUIDS/SOLIDS/INFECTIOUS SUBSTANCES

RADIOACTIVE SUBSTANCES

CORROSIVE MATERIAL

MISCELLANEOUS HAZARDOUS

MATERIALS

OTHER REGULATED MATERIALS

UNIVERSAL WASTE

TRANSPORTER CAPABILITIESMODES

7. CERTIFICATION


TDEC OFFICE USE ONLY

FAC ID

CERTIFICATION REQUIRED (Complete Form HN-CS Including Section 7)

US DOT or MC/MX NUMBER - HW TRANSPORTERS ONLY

RDA 2203PAGE 2

6. HAZARDOUS WASTE TRANSPORTERS ONLY NOTE: A COMPLETE APPLICATION INCLUDES THIS FORM, THE HAZARDOUS WASTE TRANSPORTER FEE

DETERMINATION SHEET (FORM TRFDS CN-0783), AND YOUR REMITTANCE. PERMITS ARE ISSUED ONLY AFTER

VERIFICATION OF RECEIPT OF THESE ITEMS. DATA SUPPLIED ON THIS FORM BY TRANSPORTERS LOCATED

OUTSIDE THE STATE OF TENNESSEE WILL BE VERIFIED BY REVIEWING THE DATA SUPPLIED TO THE HOME

STATE'S REGULATORY AGENCY. PERMITS ISSUED BY THE STATE OF TENNESSEE WILL BE DELAYED UNTIL THE

DATA IN YOUR HOME STATE IS MADE CURRENT WITH THAT AGENCY.

( ) CHECK HERE IF YOU DO NOT UTILIZE TRANSFER FACILITIES IN TENNESSEE6B. TRANSFER FACILITIES YOU USE

CONTACT PERSON PHONE WITH AREA CODE

COUNTYLOCATION OF TRANSFER FACILITY - HIGHWAY, ROUTE, ROAD, OR DIRECTIONS (NOT A MAIL ADDRESS)

CONTACT PERSON CONTACT PERSON MAILING ADDRESS CITY, STATE, ZIP

BUSINESS NAME OF TRANSFER FACILITY USED

1





2





3

US EPA ID NUMBER

US EPA ID NUMBER

US EPA ID NUMBER

Persons must obtain a Hazardous Waste Transporter Permit if they transport hazardous wastes that originate or terminate at points in Tennessee. The permit

will be issued by the Department upon review of a completed application renewal form, and receipt of any applicable fees. A copy of the permit must be

maintained within each transport vehicle. Permits are registered to the EPA identification number supplied on the application renewal form. The EPA

Identification number is specific to your location and the permit is therefore not transferable if you change locations. For annual renewal, the renewal forms

and fee are due no later than December 31. The permit duration is from the effective date until January 31 of the following year. The regulations require

transporters to comply not only with the permit regulations but also the operational standards that pertain to manifests, other record keeping and hazardous

waste discharges. You must also comply with any and all regulations imposed by the Tennessee Regulatory Commission, the U. S. Environmental Protection

Agency, the U. S. Department of Transportation, U.S. Department of Homeland Security and any other pertinent local, state or federal laws. To view

applicable Rules on line, visit

6C. GENERAL INFORMATION FOR HAZARDOUS WASTE TRANSPORTERS

http://www.tn.gov/sos/rules/0400/0400-12/0400-12-01/0400-12-01.htm

6A. HAZARDOUS WASTE TRANSPORTERS MODES AND CAPABILITIES

SITE, BUSINESS, OR INSTALLATION NAMEEPA ID NUMBER USED OIL REGISTRATION NUMBER

CN-1447

*

* * *

PCR (if you use 1 transfer facility in TN, all fields must be completed for 1)

PCR (if you use 2 transfer facilities in TN, all fields must be completed for 2)

PCR (if you use 3 transfer facilities in TN, all fields must be completed for 3)

P * P CR if applicable

Section 6 required for Transporters only

*must return 1 completed HN-CS form with each Annual Report packet (or each submission of forms such as initial

registration or information update etc)

P

P

P

P PCR if applicable

HN - H (Contacts)

HAZARDOUS WASTE CONTACT NOTIFICATION

PROVIDE SITE, BUSINESS, OR INSTALLATION NAMEENTER CURRENT EPA ID NUMBER USED OIL REGISTRATION NUMBER

FD

052114

STREET ADDRESS

FAX EMAIL

CITY /TOWN / LOCALITY


CITY /TOWN / LOCALITY STATE /TERRITORY ZIP / POSTAL CODE COUNTRY

1. BILLING ADDRESS - SEND BILLING INFORMATION TO THE ATTENTION OF:

BUSINESS BILLING STREET ADDRESS


2. MANAGER


3. TECHNICAL CONTACT

4. EMERGENCY CONTACT

5. OPERATOR

DEPARTMENT

COMPANY, AGENCY OR OTHER

PHONE 1 PHONE 2

RDA 2203CONTINUED

CORPORATE REGION CORPORATE DISTRICT

PHONE 1 FAX EMAILPHONE 2

STREET ADDRESS

FAX EMAIL



PHONE 1 PHONE 2

STREET ADDRESS

FAX EMAIL



PHONE 1 PHONE 2

STREET ADDRESS

FAX EMAIL



PHONE 1 PHONE 2

CN-1445

PLANT MANAGER CERTIFYING OFFICIAL AUTHORIZED REPRESENTATIVE

*

CRP

* =REQUIRED

REQUIRED=CONDITIONALLY

P CR if applicable

SUGP =SUGGESTED


P CR if applicable

*

*

* * *CR if applicable

*

**

*

*

SUGP

*

* * *

* * * *

* SUGP

* * * *

* * * *

* SUGP

* * * *

* * * *

* SUGP

* * * *

* * * *

* SUGP

P

PP

P P



State of Tennessee


Nashville, TN 37243


STREET ADDRESS

FAX EMAIL


7. CONTRACTOR 1


STREET ADDRESS

FAX EMAIL


6. LICENSE or PERMIT AGENT


STREET ADDRESS

FAX EMAIL


9. PART A OR PART B PERMIT CONTACT 1


STREET ADDRESS

FAX EMAIL


10. PART A OR PART B PERMIT CONTACT 2






PHONE 1 PHONE 2

PHONE 1 PHONE 2

PHONE 1 PHONE 2

PHONE 1 PHONE 2

SITE, BUSINESS, OR INSTALLATION NAMEEPA ID NUMBER USED OIL REGISTRATION NUMBER


TDEC OFFICE USE ONLY

FAC ID

RDA 2203PAGE 2

(FOR HAZARDOUS WASTE TRANSPORTERS, IF APPLICABLE)

8. CONTRACTOR 2

STREET ADDRESS

FAX EMAIL




PHONE 1 PHONE 2

11. CERTIFICATION

CERTIFICATION REQUIRED (Complete Form HN-CS Including Section 7)

CN-1445

P CR if applicable P CR if applicable*P CR

P CR TSD'S IF APPLICABLE

*

P P

P

P CR P Section 6 required for HW Transporters

P

P CR TSD'S IF APPLICABLEP

HN - EA

CONTINUEDCN-1446 RDA 2203

HAZARDOUS WASTE ENVIRONMENTAL ACTIVITY NOTIFICATION

PERMIT YEAR

COMMERCIAL

NON-COMMERCIAL RECYCLER

HAZARDOUS SECONDARY MATERIALS

SITE, BUSINESS, OR INSTALLATION NAME

ENTER CURRENT EPA ID NUMBER IF NOT REGISTERED, LEAVE BLANK

A.1

A.5

A.2 USED OIL REGISTRATION NUMBER IF NOT APPLICABLE, LEAVE BLANK

WITHIN TN OUTSIDE TN

COLLEGE OR UNIVERSITY

TEACHING HOSPITAL*

NON PROFIT INSTITUTE *

GENERATES, in any calendar month, 1,000 kg/mo. (2,200 lbs/mo.) or more of hazardous waste; OR GENERATES in any calendar month or ACCUMULATES at any time, 1 kg/mo. (2.2 lbs/mo.) or more of acute hazardous waste; OR GENERATES in any calendar month or ACCUMULATES at any time, 100kg/mo. (220 lbs/mo.) or more of acute hazardous spill cleanup material.

GENERATES, in any calendar month, greater than 100 kg/mo. (220 lbs/mo. but less than 1000 kg/mo. (2,200 lbs/mo.) of NON-ACUTE hazardous waste or ACCUMULATES at any time, more than 0 but less than or equal to 6000 kg/mo. (13,228 lbs/mo. of NON-ACUTE hazardous waste.

GENERATES, in any calendar month, no more than 100 kg/mo. (220 lbs/mo.) and accumulates (at any time through the entire year) under 1,000 kg (2,200 lbs) of NON-ACCUTE hazardous waste

GENERATOR, EPISODIC (SHORT TERM)

US IMPORTER

US EXPORTER

ANNUAL REPORT YEAR

A. NOTIFICATION

LARGE QUANTITY, LQG

SMALL QUANTITY, SQG

CONDITIONALLY EXEMPT, CESQG

(SEE SECTION "C")

NAICS CODE:SITE LOCATIONA.3 A.4

GENERATOR, MIXED WASTE

FD

052114

B. ENVIRONMENTAL ACTIVITY IDENTIFICATION

GENERATOR

GENERATOR, WASTEWATER EPA ID REQUIRED

ANNUAL REPORT

OTHER FORMS HN

TRANSPORTER

* OWNED BY OR HAS A FORMAL

WRITTEN AFFILIATION AGREEMENT

WITH A COLLEGE OR UNIVERSITY

ANNUAL FEES

PERMIT

YES

YES

YES

NONE

GENERATOR CATEGORIES - CHECK ONEACTIVITY CHECK ALL THAT APPLY

REQUIRED

FOR "CESQG" FURTHER REGISTRATION IS VOLUNTARY

EPA ID REQUIRED

ANNUAL REPORT

OTHER FORMS HN, TRFDS

ANNUAL FEES

PERMIT

YES

NO

YES

ANNUAL

TRANSFER FACILITY

OTHER REQUIREMENTS

EPA ID REQUIRED

ANNUAL REPORT

OTHER FORMS HN, NF

ANNUAL FEES

PERMIT

YES

NO

YES

NONE

OUT OF STATE SITES MUST POSSESS VALID EPA ID. TN DOES NOT ISSUE EPA IDs FOR OUT OF STATE SITES

OTHER REQUIREMENTS

OTHER REQUIREMENTS

x

DATE ACTIVITY BEGAN

MM DD YYYY

EXAMPLE: 03/25/2012

/ /

REQUIREDx

DATE ACTIVITY BEGAN

MM DD YYYY

EXAMPLE: 03/25/2012

/ /

REQUIREDx

DATE ACTIVITY BEGAN

MM DD YYYY

EXAMPLE: 03/25/2012

/ /

NF

WSR

TRANSPORTERS IDENTIFYING OWNERSHIP FOR SEPARATE TRANSFER FACILITY SITES ARE REQUIRED TO OBTAIN SEPARATE EPA IDs FOR EACH LOCATION

TSD FACILITIES ARE REQUIRED TO OBTAIN SEPARATE EPA ID FOR HW TRANSFER FACILITY

THESE REQUIREMENTS DO NOT

APPLY TO "CESQG" STATUS

CR

CRP

* =REQUIRED

REQUIRED

=CONDITIONALLY

SUGP =SUGGESTED


P fill in if registered *CRP fill in if applicable*

*

CRPDATE ACTIVITY

BEGAN>>> (IF

YOU SELECTED

GENERATOR)

CRPDATE ACTIVITY

BEGAN>>> (IF YOU

SELECTED TRANSPORTER)

CRPDATE ACTIVITY BEGAN>>>

(IF YOU SELECTED TRANSFER

FACILITY)

P

P P

P

P

P



State of Tennessee


Nashville, TN 37243


PAGE 2 CN-1446 RDA 2203


TDEC USE ONLYUOP NUMBER

D. CERTIFICATION REQUIRED

RECYCLER

INCINERATOR, BOILER OR INDUSTRIAL FURNACE

UNDERGROUND INJECTION CONTROL

RECEIVER OF HW FROM OFF SITE

POST CLOSURE ONLY

CORRECTIVE ACTION ONLY

FAC ID

C. NAICS CODES

EPA ID SITE OR FACILITY NAMEUSED OIL REGISTRATION NUMBER

SELECT A NAICS CODE THAT BEST CLASSIFIES THE BUSINESS AT YOUR SITE. WRITE THAT CODE IN SECTION A.4 ON PAGE 1.

CODES MAY BE FOUND AT: http://www.census.gov/eos/www/naics/

BURNER

COLLECTION CENTER

FUEL MARKETER

TRANSFER FACILITY

TRANSPORTER

(COMMERCIAL ONLY)

PROCESSOR / RE-REFINER

USED OIL

OTHER REQUIREMENTS

EPA ID REQUIRED

ANNUAL REPORT

OTHER FORMS HN

ANNUAL FEES

PERMIT

#1 THRU #5

NONE

CHECK ALL THAT APPLY

UOP # REQUIRED #1 THRU #6

REQUIREDx

DATE ACTIVITY BEGAN

MM DD YYYY

EXAMPLE: 03/25/2012

/ /

TREATMENT STORAGE and DISPOSAL (TSDF)

OTHER REQUIREMENTS

EPA ID REQUIRED

ANNUAL REPORT

OTHER FORMS HN, NF

ANNUAL FEES

PERMIT

YES

YES

YES

YES


REQUIREDx

DATE ACTIVITY BEGAN

MM DD YYYY

EXAMPLE: 03/25/2012

/ /EXTENSIVE PERMITTING PROCESS INVOLVED FOR TSDs; CONTACT HW PERMITTING STAFF

UNIVERSAL WASTE

OTHER REQUIREMENTS

EPA ID REQUIRED

ANNUAL REPORT

OTHER FORMS HN

ANNUAL FEES

PERMITS

YES

NO

YES

NONE


REQUIREDx

DATE ACTIVITY BEGAN

MM DD YYYY

EXAMPLE: 03/25/2012

/ /

BATTERIES

PESTICIDES

LAMPS / BULBS

MERCURY CONTAINING EQUIPMENT

SMALL QUANTITY HANDLER

TRANSPORTER

RECYCLER (ON-SITE)

LARGE QUANTITY HANDLER

DESTINATION FACILITY1.

2.

3.

4.

#1

#1, #2

NF

1.

2.

3.

4.

5.

6.

NF

UO-D

UO-AR

#5

#1 THRU #5

#1 THRU #7

#1 THRU #5

#1 THRU #5

#3 THRU #5

LAMP CRUSHER, COMMERCIAL

#1, #2

#1, #2

COLLECTION CENTER(DIY - DO IT YOURSELFER)

7.

(Complete Form HN-CS Including Section 7)

IF YOU CHECKED #2 OR #3 ABOVE, CHECK BELOW ALL THAT YOU MANAGE OR GENERATE

CRPDATE ACTIVITY BEGAN>>>

(IF YOU SELECTED USED OIL)

CRPDATE ACTIVITY

BEGAN>>> (IF YOU

SELECTED TREATMENT

STORAGE ANS DISPOSAL)

CRPDATE ACTIVITY

BEGAN>>> (IF YOU

SELECTED UNIVERSAL

WASTE)

*

SUGP SUGP SUGP

P

P

P

1a- WASTE STREAM NAME

US EPA ID NUMBER BUSINESS NAME

1b- HOW IS THIS WASTE GENERATED?

1o- WASTE FORM CODE1n- REACTIVE CODES

2a- HAZARDOUS WASTE CONSTITUENT

1m- BTU PER POUND1l- FLASH POINT

3a- AMOUNT GENERATED

2b- LOWER VALUE

ITEM 2- WASTE STREAM CONSTITUENTS

ITEM 3- ANNUAL GENERATION AND HANDLING NOTE:

ITEM 4- OFFSITE SHIPPING

1 j - MONTHLY MAXIMUM GENERATED

I AM REPORTING IN KILOGRAMS

I AM REPORTING IN POUNDS

DATE GENERATION BEGAN

WASTE STREAM NUMBER

ONE TIME GENERATION

REGULARLY GENERATED

INTERMITTENTLY GENERATED

1d- GENERATION FREQUENCY

ACTIVE

CLOSED

RE-ACTIVATED

1i- TN / RCRA RADIOACTIVE MIXED WASTE

IGNITABLE

TCLP

CORROSIVE

REACTIVE

LISTED

1p- NAICS CODE - up to 2

ITEM 1- HAZARDOUS WASTE STREAM DESCRIPTION AND PROCESS

1h- EPA HAZARDOUS WASTE CODES

1q- U.S. DOT SHIPPING NAME 1r- U.S. DOT HAZARD CLASS 1s- U.S. DOT ID CODE

LIST CODES IN THIS ORDER: P, D, F, U, AND K

INFORMATION UPDATEANNUAL REPORTREPORT YEAR NEW WASTE STREAM

1c- UNITS OF MEASURE

1e- WASTE STREAM STATUS 1f- HAZARD CRITERIA 1g- GENERATION DATES

1k- pH

H

DATE NO LONGER GENERATED

CHECK ONE: USE SAME UNIT OF MEASURE ON ALL ATTACHMENTS.

1(b)1- SOURCE CODE

G

( ) Kg

( ) lbs

2c- UPPER VALUE

2d- CONCENTRATIONS

PPM %VOLUME %WEIGHT

1

2

3

4

5

3b- AMOUNT ONSITE JAN 1st 3c- AMOUNT ONSITE DEC 31st 3d- AMOUNT HANDLED

4a- TOTAL AMOUNT SHIPPED OFFSITE 4b- STATE CODES: STORAGE AND FINAL DISPOSAL / TREATMENT 4c- EPA MANAGEMENT METHOD

Kg

lbs lbs / gal

3a + 3b - 3c = 3d 3d = 4a + 5a + 5b + 5c + 5d

(CONTINUED)

(SEE 1g)

(YES OR NO)

W W W

H

H

CN-0773 (Rev. 11-14) RDA 2203

FORM WSR

FD

112014

HAZARDOUS WASTE STREAM REPORT

CRP

=REQUIRED

REQUIRED

=CONDITIONALLY

SUGP =SUGGESTED


*P

*

* *

**

*

* *

* * *

* *

* * *

* ITEM 3 ANNUAL REPORTING ONLY

* ITEM 4 ANNUAL REPORTING ONLY

CRPP CRPP CRPP CRPP

CRPPNEW SITES WILL NOT HAVE

AN EPA ID NUMBER

*

CRPP

CRPP

CRPPNEW SITES MAY NOT HAVE

INFORMATION FOR ITEM 2 AT THE

TIME OF REGISTRATION; ONCE

KNOWN, INFORMATION MUST BE

UPDATED AS SOON AS POSSIBLE

*



State of Tennessee


Nashville, TN 37243


5a- AMOUNT OF 3d HANDLED ONSITE

ITEM 5- TSD PERMITTED STORAGE ONLY - OR - FACILITY'S ONSITE HANDLING or TREATMENT

ITEM 7- FACILITY COMMENTS

TDEC USE ONLY

REVIEWERSTATUS REC'D DATEFURTHER REPORTING

HAZARDOUS WASTE STREAM REPORT - FORM WSR

H

(NH) NOT HAZARDOUS

(TR) TREATMENT RESIDUE

(RR) RES RECOVERY

(PE) PARTIAL EXEMPTION

(H) HAZARDOUS

(N) NO LONGER GEN

(V) VARIANCE GRANTED

(R) MIXED RAD WASTE

(C) CORR ACTION

(W) WASTE WATER Rx

(U) UNIVERSAL WASTE

(CF) COMPARABLE FUELS

CN-0773 (Rev. 11-14)

US EPA ID NUMBER BUSINESS NAME

WASTE STREAM #

STATE CODES: TREATMENT, STORAGE, DISPOSAL, HANDLING EPA MANAGEMENT METHOD

5b- AMOUNT OF 3d HANDLED ONSITE

H


5c- AMOUNT OF 3d HANDLED ONSITE

H


5d- AMOUNT OF 3d HANDLED ONSITE

H


ITEM 6- HAZARDOUS WASTE REDUCTION

6a- THIS YEAR RATIO 6b- GOAL YEAR RATIO 6c- GOAL YEAR 6d- WASTE / TOXICITY REDUCTION EFFORT CODES

6e- WASTE REDUCTION IMPEDIMENT CODES

6f- CHANGE IN TOXICITY

INCREASE

DECREASE

NO CHANGE

6g- NARRATIVE: EXPLAIN REPORTED DATA (IF APPLICABLE)

6h- NARRATIVE: IF NO NUMERIC GOAL EXPLAIN WHY

YES NO

NOTES

RDA 2203

CERTIFICATION

PAGE 2

CERTIFICATION REQUIRED

(Complete Form HN-CS Including Section 7)*

* *CRPP

CRPPFOR ITEM 6 - NEW SITES WILL NOT HAVE A WASTE

REDUCTION PLAN - SEE INSTRUCTIONS

CRPPFOR ITEM 5 - ANNUAL REPORTING AS REQUIRED- NEW SITES

NOT REQUIRED TO COMPLETE THIS SECTION

Documents

New Forms and Required Fields Guide...15. CN-1044 UO-AR USED OIL ANNUAL REPORT 14. UO-D 15. UO-AR 8. TSD-FDS Note: Only one HN-CS form is required to be returned with each annual report