Hazardous Waste Storage Extension Application

Generators Information:

Generator's Name:

EPA ID#:

Applicant's Name:

Applicant's Phone#:

Site Address:

Address Line 1:

Suite#:

City:

State:

Zip:

Mailing Address:

Address Line 1:

Suite#:

City:

State:

Zip:

Description of Hazardous Waste:

Description and Dates

Description and Dates
Waste Composition: Waste Code: Concentration of Constituents (If known): Measurement: Drums Qty: Type: Tanks Qty: Type: Bins Qty: Type: Other Specify: Qty: Type: Describe the Storage Area: Example: include waste container, tank labeling or marking, containment system, berms, warning signs, etc. Also include photographs with your submission to support the description of the storage area. Initial Accumulation Start Date: Date of 90-Day Accumulation Limit: Number of Additional Days Requested (30-Day Maximum):

Waste Composition:

Waste Code:

Concentration of Constituents (If known):

Measurement:

Drums

Qty:

Type:

Tanks

Qty:

Type:

Bins

Qty:

Type:

Other

Specify:

Qty:

Type:

Describe the Storage Area:

Example: include waste container, tank labeling or marking, containment system, berms, warning signs, etc. Also include photographs with your submission to support the description of the storage area.

Initial Accumulation Start Date:

Date of 90-Day Accumulation Limit:

Number of Additional Days Requested (30-Day Maximum):

Detailed Reason for Storage Extension Request:

Certify:

I certify that the information given is accurate and true at the time of this submission.