Hazardous Waste Generator Tank Survey {52386}

HAZARDOUS WASTE GENERATOR TANK SURVEY State Form 52386 (9-05) Indiana Department of Environmental Management RCRA ID NUMBER FACILITY NAME: LOCATION ADDRESS: CITY, STATE, ZIP CODE : COUNTY: TANK DESCRIPTION TANK CONTENTS TANK CAPACITY (IN GALLONS): IS THE TANK IN ACTIVE SERVICE? YES NO CONSTRUCTION MATERIAL: DATE TANK WAS PUT INTO SERVICE: (MM/DD/YYYY) IS THE TANK UNDERGROUND? STEEL LINER FIBERGLASS DOUBLEWALL PLASTIC VAULT YES OTHER OTHER NO SECONDARY CONTAINMENT: HAZARDOUS WASTE CODES FIRST NAME: NONE LAST NAME : TITLE : E-MAIL: PHONE NUMBER: I certify under penalty of law that this document and all attachments were prepared under my direction or supervision. Based upon my own knowledge and or inquiry of the person(s) directly responsible for gathering the information reported on this document, the information submitted is, to the best of my knowledge, true, accurate, and complete. SIGNATURE __________________________________________________________________________________________ PAGE OF American LegalNet, Inc. www.FormsWorkflow.com HAZARDOUS WASTE GENERATOR TANK SURVEY INSTRUCTIONS Standards for hazardous waste generator tank management are set forth in 329 IAC 3.1 rule 10 and in Federal regulation 40 CFR Subpart J. In order for IDEM compliance staff to gain an understanding of the number and types of tanks in Indiana which are affected by these rules, we request that you complete this survey. Please copy the form as needed and fill out one form for each hazardous waste storage tank your facility operates. SIGN AND RETURN TO: Indiana Department of Environmental Management Office of Land Quality, Facilities Data Analysis Section 100 North Senate Ave, Room 1101 Indianapolis, IN 46204-2251 Nancy Heacox 317-232-7956 nheacox at idem.in.gov QUESTIONS: American LegalNet, Inc. www.FormsWorkflow.com