RCRA SUBTITLE C SITE IDENTIFICATION FORM

Transcription

1 United s EnvironmentalProtection Agency RCRA SUBTITLE C SITE IDENTIFICATION 1. Reason for Submittal MARK ALL BOX(ES) THAT APPLY 2. Site EPA ID Number To provide Initial Notification of Regulated Waste Activity (to obtain an EPA ID Number for hazardous waste, universal waste, or used oil activities). To provide Subsequent Notification of Regulated Waste Activity (to update site identification information). As a component of a First RCRA Hazardous Waste Part A Permit Application. As a component of a Revised RCRA Hazardous Waste Part A Permit Application. To deactivate the site. Site is inactive with no Regulated Waste Activity. Implementer - Agency that is Implementer of Record for Handler. As a component of the Hazardous Waste Report.(If marked, see sub-bullet below) (*)<I>Site was a TSD Facility and/or generator >= 1,000 kg of hazardous waste, >1kg of acute hazardous waste, or >100 kg of acute hazardous waste spill cleanup in one or more months of the reports year ( or equivalent LQG regulations)</i> 3. Site Name CVS PHARMACY # Site Location information Street Address: 1605 Telegraph Road City, Town or Village: Wilmington : DE County Name: New Castle Zip Code: Site Land Type County District Federal Indian Municipal Other Private Unknown 6. North American industry Classification System (NAICS) Code (s) for the Site A. C B. D. 7. Site Mailing Adress Street Address: 1 Cvs Drive Mail Code 2340 City, Town or Village: Woonsocket : RI Country: US Zip Code: Page 1 of 0

2 8. Site Contact Person 9. Operator and Legal Owner of the Site Name: Wilkinson, Nicole Title: Director, Corporate Environmental Street Address: 1 CVS Drive Mail Code 2340 City or Town : WOONSOCKET : RI Phone Number: Ext. Fax Number: Address: wendy.brant@cvscaremark.com Current Operator Organization Name: DELAWARE CVS PHARMACY, LLC Date Became Owner/Operator 10/7/2012 Country District Federal Indian Municipal Other Private Street Address: Unknown One CVS Drive-23062A City, Town or Village: Woonsocket : RI Country: US Zip Code: Phone Number: Current Owner Organization Name: DELAWARE CVS PHARMACY, LLC Date Became Owner/Operator 10/7/2012 Country District Federal Indian Municipal Other Private Street Address: Unknown One CVS Drive-23062A City, Town or Village: Woonsocket : RI Country: US Zip Code: Phone Number: Page 2 of 0

3 10. Type of Regulated Waste Ativity A. Hazardous Waste Activities Y N 1. Generator of Hazardous Waste Y N 5. Transporter of Hazardous Waste a. LQG: Greater than 1,000 kg/mo (2,200 lb/mo) of non-acute hazardous waste; or b. SQG: 100 to 1,000 (220-2,200 lb/mo) of non-acute hazardous waste; or a. Transporter b. Transfer Facility Y N 6. Treater, Storer, or Disposer of Hazardous Waste (at your site) c. CESQG: Less than 100 kg/mo (220 lb/mo) of non-acute hazardous waste Other Generator Activities Y N Note: A hazardous waste permit is required for this activity. 7. Recycler of Hazardous Waste (at your site) Y N 2. Short Term Generator Y N 8. Excempt Boiler and/or Industrial Furnace Y N 3. United s Importer of hazardous Waste a. Small Quantity On-Site Burner Exemption b. Smelting, Melting, and Refining Y N 4. Mixed Waste (Hazardous and Radioactive) Generator Y N 9. Underground injection Control B. Universal Waste Activities C. Used Oil Activities Y N 10. Receives Hazardous Waste from off-site Y N 1. Large Quantity Handler of Universal Waste (accumulate 5,000 kg or more) Y N 1. Used Oil Transporter a. Transporter Manage b. Transfer Facility a. Batteries Y N 2. Used Oil Processor and/or Re-refiner b. Pesticides a. Processor c. Mercury containing equipment b. Re-refiner d. Lamps Y N 3. Off-Specification Used Oil Burner e. Other Y N 4. Used Oil Fuel Marketer Y N 2. Destination Facility for Universal Waste a. Marketer who directs shipment of Off-Specification Used Oil to Off- Specification Used Oil Burner Note: A hazardous waste permit may be reuired for this activity. b. Marketer who first claims used oil meets the specifications Page 3 of 0

4 11. Description of Hazardous Wastes A. Waste Codes for Federally Regulated Hazardous Wastes D001 D007 D016 D039 P188 U035 U072 U150 U200 U Comments D002 D008 D018 P001 U002 U044 U089 U151 U201 U279 Site contact information updated 13. Certification D004 D009 D024 P012 U010 U058 U122 U154 U204 U411 D005 D010 D027 P075 U031 U059 U129 U165 U205 D006 D011 D035 P081 U034 U070 U132 U188 U206 I certify under penalty of law that this document and all attachements 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. For the RCRA Hazardous Waste Part A Permit Application, all operator(s) and owner(s) must sign (see 40 CFR (b) and ). Signature of operator, owner or an authorized representative Name and Ofiicial Title Date Signed (mm/dd/yyyy) Savage, Charles - Regulatory Compliance Specialist 2/7/2017 Savage, Charles - Regulatory Compliance Specialist 2/7/2017 Page 4 of 0

5 GM WASTE GENERATION AND MANAGEMENT Instructions: Please see the detailed instructions on pages 18 to 26 of the booklet before completing this form. Sec. 1 A. Waste Description Acute Toxic Solids B. EPA Hazardous Waste Codes P001 P075 D. Source Code G11 Management Method Code for Source Code G25 H _ _ _ E. Form Code W004 C. hazardous Waste Code F. Quantity generated in 2016 UOM N/A Density 0.00 G. Waste minimization code X lbs/gal sg Sec. 2 Was any of this waste managed on site? (pages 24 and 25) Sec. 3 Was any of this waste shipped off site for treatment, disposal or recycling? (pages 25 and 26) OFF-SITE PROCESSING System EPA ID of Facility to which waste was shipped Off-Site Management Method Code Quantity treated, disposed or recycled on site in RID H Page 5 of 0

6 GM WASTE GENERATION AND MANAGEMENT Instructions: Please see the detailed instructions on pages 18 to 26 of the booklet before completing this form. Sec. 1 A. Waste Description Aerosols, Flammable B. EPA Hazardous Waste Codes D001 D. Source Code G11 Management Method Code for Source Code G25 H _ _ _ E. Form Code W801 C. hazardous Waste Code F. Quantity generated in 2016 UOM N/A Density 0.00 G. Waste minimization code X lbs/gal sg Sec. 2 Was any of this waste managed on site? (pages 24 and 25) Sec. 3 Was any of this waste shipped off site for treatment, disposal or recycling? (pages 25 and 26) OFF-SITE PROCESSING System EPA ID of Facility to which waste was shipped Off-Site Management Method Code Quantity treated, disposed or recycled on site in RID H PAD H Page 6 of 0

7 GM WASTE GENERATION AND MANAGEMENT Instructions: Please see the detailed instructions on pages 18 to 26 of the booklet before completing this form. Sec. 1 A. Waste Description Empty P-Listed Pharmaceutical Containers B. EPA Hazardous Waste Codes P001 D. Source Code G11 Management Method Code for Source Code G25 H _ _ _ E. Form Code W004 C. hazardous Waste Code F. Quantity generated in 2016 UOM N/A Density 0.00 G. Waste minimization code X lbs/gal sg Sec. 2 Was any of this waste managed on site? (pages 24 and 25) Sec. 3 Was any of this waste shipped off site for treatment, disposal or recycling? (pages 25 and 26) OFF-SITE PROCESSING System EPA ID of Facility to which waste was shipped Off-Site Management Method Code Quantity treated, disposed or recycled on site in RID H INR H Page 7 of 0

8 GM WASTE GENERATION AND MANAGEMENT Instructions: Please see the detailed instructions on pages 18 to 26 of the booklet before completing this form. Sec. 1 A. Waste Description Flammable liquids B. EPA Hazardous Waste Codes D001 U002 D. Source Code G11 Management Method Code for Source Code G25 H _ _ _ E. Form Code W219 C. hazardous Waste Code F. Quantity generated in 2016 UOM N/A Density 0.00 G. Waste minimization code X lbs/gal sg Sec. 2 Was any of this waste managed on site? (pages 24 and 25) Sec. 3 Was any of this waste shipped off site for treatment, disposal or recycling? (pages 25 and 26) OFF-SITE PROCESSING System EPA ID of Facility to which waste was shipped Off-Site Management Method Code Quantity treated, disposed or recycled on site in PAD H Page 8 of 0

9 GM WASTE GENERATION AND MANAGEMENT Instructions: Please see the detailed instructions on pages 18 to 26 of the booklet before completing this form. Sec. 1 A. Waste Description Residue weight does not exceed lbs B. EPA Hazardous Waste Codes P001 D. Source Code G11 Management Method Code for Source Code G25 H _ _ _ E. Form Code W004 C. hazardous Waste Code F. Quantity generated in 2016 UOM N/A Density 0.00 G. Waste minimization code X lbs/gal sg Sec. 2 Was any of this waste managed on site? (pages 24 and 25) Sec. 3 Was any of this waste shipped off site for treatment, disposal or recycling? (pages 25 and 26) OFF-SITE PROCESSING System EPA ID of Facility to which waste was shipped Off-Site Management Method Code Quantity treated, disposed or recycled on site in RID H Page 9 of 0

10 GM WASTE GENERATION AND MANAGEMENT Instructions: Please see the detailed instructions on pages 18 to 26 of the booklet before completing this form. Sec. 1 A. Waste Description Rx Toxic Solids B. EPA Hazardous Waste Codes D007 D010 D. Source Code G11 Management Method Code for Source Code G25 H _ _ _ E. Form Code W005 C. hazardous Waste Code F. Quantity generated in 2016 UOM N/A Density 0.00 G. Waste minimization code X lbs/gal sg Sec. 2 Was any of this waste managed on site? (pages 24 and 25) Sec. 3 Was any of this waste shipped off site for treatment, disposal or recycling? (pages 25 and 26) OFF-SITE PROCESSING System EPA ID of Facility to which waste was shipped Off-Site Management Method Code Quantity treated, disposed or recycled on site in RID H INR H Page 10 of 0

11 OI OFF-SITE IDENTIFICATION Instructions: Please read the detailed instructions in the booklet before completing this form. A. EPA ID No. of Off-Site installation or transporter INR Stericycle, Inc. C. Handler Type Generator Transporter TSDR Facility Street City 2670 Executive Drive Indianapolis IN Zip Page 11 of 0

12 OI OFF-SITE IDENTIFICATION Instructions: Please read the detailed instructions in the booklet before completing this form. A. EPA ID No. of Off-Site installation or transporter PAD Republic Environmental Systems C. Handler Type Generator Transporter TSDR Facility Street City 2869 Sandstone Drive Hatfield PA Zip Page 12 of 0

13 OI OFF-SITE IDENTIFICATION Instructions: Please read the detailed instructions in the booklet before completing this form. A. EPA ID No. of Off-Site installation or transporter RID Northland Environmental, LLC C. Handler Type Generator Transporter TSDR Facility Street City 275 Allens Avenue Providence RI Zip Page 13 of 0

14 OI OFF-SITE IDENTIFICATION Instructions: Please read the detailed instructions in the booklet before completing this form. A. EPA ID No. of Off-Site installation or transporter CTD Stericycle, Inc. C. Handler Type Generator Transporter TSDR Facility Street City 80 Industrial Park Road Middletown CT Zip Page 14 of 0

15 OI OFF-SITE IDENTIFICATION Instructions: Please read the detailed instructions in the booklet before completing this form. A. EPA ID No. of Off-Site installation or transporter PAD Republic Env Systems Transport Group C. Handler Type Generator Transporter TSDR Facility Street City 21 Church Road Hatfield PA Zip Page 15 of 0

16 OI OFF-SITE IDENTIFICATION Instructions: Please read the detailed instructions in the booklet before completing this form. A. EPA ID No. of Off-Site installation or transporter MNS Stericycle Specialty Waste Solutions Inc C. Handler Type Generator Transporter TSDR Facility Street City th Court Northeast Blaine MN Zip Page 16 of 0

17 OI OFF-SITE IDENTIFICATION Instructions: Please read the detailed instructions in the booklet before completing this form. A. EPA ID No. of Off-Site installation or transporter NJR Disposal Consultant Services, Inc. C. Handler Type Generator Transporter TSDR Facility Street City 28 Howard Street Piscataway NJ Zip Page 17 of 0