W. Va. Code R. agency 33, tit. 33, ser. 33-26, app I
HAZARDOUS WASTE EMERGENCY RESPONSE FUND
FEE ASSESSMENT REPORT
Company Name: __________________________________
EPA I.D.#: ___________________________________________
Generator Location: _____________________________________
1. The amount of hazardous wastes generated during the 20____calendar year, EXCLUDING NONHAZARDOUS CONSTITUENTS.
____Tons
2. The amount of hazardous wastes generated (from the amount determined in #1)that were treated or disposed of off-site, but remained hazardous.
____Tons
3. The amount of hazardous wastes generated (from the amount determined in #1) that were treated or disposed of on-site, but remained hazardous.
____Tons
4. The amount of hazardous wastes generated (from the amount determined in #1) that were treated off-site, so that such wastes were rendered nonhazardous.
____Tons
5. The amount of hazardous wastes generated (from the amount determined in #1) that were treated on-site, so that such wastes were rendered nonhazardous.
_____Tons
6. Provide a brief narrative of the method(s)used to determine the amount given in #1, including method(s) used to determine the nonhazardous constituents.
7. If the total of items #2 through #5 is not equal to item #1, provide reasons for the difference.
CERTFICIATION:
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 upon my inquiry of the person or persons who managed 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.
_____________________________ ___________________________
Print or Type Name of Title
Representative
W. Va. Code R. agency 33, tit. 33, ser. 33-26, app I