Mo 780 1097 Form – Fill Out and Use This PDF

NOTE PLEASE READ INSTRUCTIONS AND EITHER PRINT OR TYPE
SECTION A - REPORT IDENTIFICATION (Complete Item 1 or				Item 2, NOT BOTH)
	1. ANNUAL			2. QUARTERLY				3. PAGE
				FOR THE PERIOD ENDING
					9/30 _________ (YEAR)	12/31 _________ (YEAR)
	7/1 __________ (YEAR)		to 6/30 __________ (YEAR)					1
					3/31 _________ (YEAR)	6/30 _________ (YEAR)		______ OF _____
SECTION B - GENERATOR IDENTIFICATION
NOTE: Complete only those items where the information has changed.
4. GENERATOR’S NAME		HAS CHANGED
5. GENERATOR CONTACT PERSON (NAME) HAS CHANGED						TELEPHONE NUMBER HAS CHANGED
6. MAILING ADDRESS		HAS CHANGED			CITY		STATE		ZIP CODE
7. PLANT SITE ADDRESS					CITY		STATE		ZIP CODE
8. NAME OF PARENT FIRM		HAS CHANGED

12.

SECTION E - CERTIFICATION STATEMENT

I certify under penalty of law that I have personally examined an am familiar with the information submitted in this and all attached documents and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

MO 780-1097 (03-14)

MANIFEST SUMMARY REPORT DNR-HWG-11

NOTE

PLEASE READ INSTRUCTIONS AND EITHER PRINT OR TYPE

ATTENTION: Summarize all shipments made

to the

SECTION F - REPORT IDENTIFICATION (AS SHOWN

ON PART 1)

1. FOR THE PERIOD ENDING (CHECK ONE & FILL IN YEAR)

2. PAGE

Hazardous Waste Management Facility you have identified

in Section G below. Additional pages are required for each

9/30 ___________ (YEAR)

12/31 ___________ (YEAR)

off-site management facility listed.

3/31 ___________ (YEAR)

6/30 ___________ (YEAR)

________ OF _______

SECTION G - FACILITY IDENTIFICATION

3. FACILITY NAME (NAME OF OFF-SITE LOCATION WHERE WASTE WAS DELIVERED)

4. FACILITY’S EPA I.D. NUMBER

5. FACILITY SITE ADDRESS

CITY

STATE

ZIP CODE

SECTION H - WASTE IDENTIFICATION

L

6.

7.

8.

9.

10.

11.

12.

I

DESCRIPTION OF WASTE

TAX

UNIT

MANAGEMENT

N

SHIPPED TO THE

EPA HAZARDOUS

CODE

TOTAL AMOUNT

OF

SPECIFIC

METHOD

E

FACILITY LISTED ABOVE

WASTE NUMBER

(SEE INST.)

OF WASTE

MEAS.

GRAVITY

CODE

1

•

H

2

H

•

3

H

•

4

H

•

5

H

•

6

H

•

SECTION I - TRANSPORTATION SERVICES

UTILIZED

13. COMPANY NAME

14. US EPA ID NUMBER

a

b

c

SECTION J - COMMENTS

15.

MO 780-1097 (03-14)

MANIFEST SUMMARY REPORT DNR-HWG-11

GENERAL INSTRUCTIONS FOR

THE GENERATOR’S HAZARDOUS WASTE

SUMMARY REPORT - DNR HWG-11

INTRODUCTION

1.All registered generators must report to the Department of Natural Resources all hazardous waste shipped off-site either quarterly or annually:

(A)Quarterly - If you are a large quantity generator and ship a reportable quantity regularly or intermittently or;

(B)Annually - If you are a small quantity generator, or are a large quantity generator and you have not shipped a reportable quantity of waste for the entire reporting year, or ship a reportable quantity only once a year.

2.All generators must read and hand-sign the generator certification in Section E. Unsigned reports are considered to be incomplete.

3.Used Oil Generators

Used oil which is to be recycled is not considered to be a hazardous waste. It does not have to be included when completing this report. NOTE-Burning for energy recovery is considered to be a form of recycling.

Used oil which is to be disposed of rather than recycled is considered a hazardous waste. It must be managed as well as disposed of as a hazardous waste. It must be included in this report along with all of your other hazardous waste. When reporting used oil use Hazardous Waste Code D098.

4.Fluorescent Lamp/Bulb Generators

Unbroken fluorescent lamps/bulbs that are sent for recycling are not considered hazardous, and do not have to be reported. Flourescent lamps may be handled as a universal waste. Flourescent lamps handled as a hazardous waste must be reported.

5.Universal Waste Generators

Universal waste is not a hazardous waste and should NOT be reported.

6.Reports are based on state fiscal years which begins July 1 and ends June 30 of each year.

1st quarter begins July 1 and ends September 30 2nd quarter begins October 1 and ends December 31 3rd quarter begins January 1 and ends March 31 4th quarter begins April 1 and ends June 30

7.Reports are due within forty-five (45) days after the end of each respective reporting period.

8.A reportable quantity of hazardous waste is 100 kilograms (220 pounds) of most types of hazardous waste. However, it may be as little as 1 kilogram (2.2 pounds) of acutely toxic wastes. A generator must report quarterly to the department when these quantities are actually produced within any month or accumulated from previous months.

9.Questions concerning the Generator’s Hazardous Waste Summary Report should be directed to the Missouri Department of Natural Resources, Hazardous Waste Program, P.O. Box 176, Jefferson City, MO 65102, or call (573) 751-3176.

MO 780-1097 (03-14)

PAGE 1

PART 1

INSTRUCTIONS FOR THE GENERATOR’S HAZARDOUS

WASTE SUMMARY REPORT - DNR HWG-11

IMPORTANT: BEFORE COPYING FORM PLEASE ATTACH THE SITE IDENTIFICATION LABEL TO THE TOP OF THE FORM OR ENTER THE REQUESTED INFORMATION.

SECTION A: REPORT INFORMATION

Item 1. ANNUAL REPORT - Annual reports are based on a reporting year which begins July 1 and ends June 30 of the following year.

Report annually if you are a small quantity generator, or ship a reportable quantity ONLY one time during the reporting year, or have not shipped a reportable quantity during the reporting year.

Item 2. QUARTERLY REPORT - Check the appropriate box which identifies when the reporting periods end. Then enter the year on the line immediately following the checked box.

Note: Quarterly reports are based on reporting year quarters: July 1 to September 30; October 1 to December 31; January 1 to March 31; April 1 to June 30.

Item 3. NUMBER OF PAGES - Enter the number of pages necessary to complete this report. (First page plus the total number of Part 2’s used.)

SECTION B: GENERATOR IDENTIFICATION

The items in this section are to be completed only when the information for that particular item has changed.

Item 4. GENERATOR NAME - Enter the new name of your company.

Item 5. GENERATOR CONTACT PERSON - Enter the name of the person now primarily responsible for the information contained in this report. Then enter the phone number of the contact person.

Item 6. MAILING ADDRESS - Enter the new street and number or P.O. Box number, city, state, and zip code where the U.S. Postal Service delivers your facility’s mail.

Item 7. PLANT SITE ADDRESS/LOCATION - Enter the street and number or route number (do not enter a P.O. Box number), city, state, and zip code which is the actual site address of your facility. If the plant address is the same as the mailing address, enter the words “same as above”.

Item 8. NAME OF PARENT FIRM - Enter the new legal owner’s name and address.

MO 780-1097 (03-14)

PAGE 2

SECTION C: STATUS OF WASTE GENERATED

Item 9. NUMBER OF SHIPMENTS MADE - If a reportable quantity* of hazardous waste was shipped off-site during any month, enter the number of shipments made this reporting period. Note that the number of shipments is not necessarily the same as the number of manifests, since more than one manifest can be used for a single shipment.

NOTE: You must complete the Generator Hazardous Waste Summary Report, Part 2, (one for each off-site facility used), sign the certification statement, and transmit this report to the department. If no shipments were made for the reporting period enter zero and then check item 10 or item 11, whichever is appropriate.

Item 10. REPORTABLE QUANTITY NOT GENERATED - If your facility is registered with the department as an “intermittent” generator or having the potential and registered as a contingency for unexpected situations (spills, etc.) and/or your facility has not generated nor accumulated reportable quantities* of hazardous waste, place a check mark in the box.

Item 11. REPORTABLE QUANTITY GENERATED BUT NOT SHIPPED OFF-SITE THIS QUARTER - If your facility did not ship waste off-site and a reportable quantity* has accumulated on-site during the reporting period, place a check mark in the box, sign the certification and transmit to the department.

NOTE: Do not complete a Part 2 until the reporting period in which the waste is actually shipped off site.

SECTION D: COMMENTS

Item 12. COMMENTS: Enter any comments which you feel may need explanation for any of the above entries. If additional space is needed, attach a sheet of paper.

SECTION E: CERTIFICATION STATEMENT

The generator or his/her authorized representative (e.g., the plant manager, superintendent or person of equivalent responsibility) must sign and date the certification by hand where indicated. The printed or typed name of the person signing the report must also be included where indicated.

PART 2

INSTRUCTIONS FOR

GENERATOR’S HAZARDOUS WASTE

SUMMARY REPORT - DNR HWG-11

SECTION F: REPORT IDENTIFICATION

Item 1. FOR THE QUARTER ENDING - Check the appropriate box which identifies the reporting quarter’s end then enter the year.

NOTE: This information must be exactly the same as recorded on the Part 1. When reporting annually check the 6/30 box and enter the year.

Item 2. PAGE _____ OF _____ - Enter the consecutive page number this page represents then the total number of pages necessary to

complete this report.

SECTION G: FACILITY IDENTIFICATION

Item 3. FACILITY NAME - Enter the name of the facility to which all waste listed on this page was shipped. If the waste was shipped to a foreign country, enter the name of the exporter and then enter the name and address of the foreign facility in Section J: Comments.

Item 4. FACILITY’S EPA IDENTIFICATION NUMBER - Enter the U.S. EPA identification number of the facility to which you sent the waste described under Section H. If the waste was shipped to a foreign facility, enter the U.S. EPA identification number issued to the exporter.

Item 5. FACILITY SITE ADDRESS: - Enter the site address (not a P.O. Box Number) of the facility (or exporter if the waste was shipped to a foreign country).

SECTION H: WASTE IDENTIFICATION

A separate entry is required for each different waste or waste mixture that was shipped to the facility identified in Section G. Same waste types shipped to the same facility may be summarized.

Item 6. DESCRIPTION OF WASTE - For hazardous wastes that are listed under 40 CFR 261.30, enter the EPA listed name, abbreviated if necessary. Where mixtures of listed wastes were shipped, enter the description which best describes the waste.

*See page 1, item 8 for reportable quantity definition.

MO 780-1097 (03-14)

PAGE 3

For unlisted hazardous waste identified by characteristic (i.e., ignitable, corrosive, reactive, or EP toxic) under 40 CFR 261.20, please include the following: (1) the description of the characteristic in which you believe best describes the waste; (2) the specific manufacturing or other process generating the waste; and (3) the chemical or generic chemical name of the waste, if known.

EXAMPLE:

	SECTION H - WASTE IDENTIFICATION
L	6.						7.						8.	9.	10.	11.		12.
I	DESCRIPTION OF WASTE												TAX		UNIT		MANAGEMENT
N	SHIPPED TO THE			EPA HAZARDOUS									CODE	TOTAL AMOUNT	OF	SPECIFIC		METHOD
E	FACILITY LISTED ABOVE			WASTE NUMBER									(SEE INST.)	OF WASTE	MEAS.	GRAVITY		CODE
1		F		0		0		3
	Spent acetone and toluene used in painting.	F		0		0		5						14923	P	•	H	0	2		0
2	Corrosive metal sludge contains cadmium	D		0		0		2
		D		0		0		6						8250	P
	and nickel.															•	H	1	2		9
Item 7. U.S. EPA HAZARDOUS WASTE NUMBER

For listed wastes, enter the four (4)-character U.S. EPA Hazardous Waste Number from 40 CFR 261.30 which identifies the waste. For unlisted wastes which exhibit hazardous characteristics, enter the four (4)-character U.S. EPA Hazardous Waste Number from 40 CFR 261.20 which is applicable to the waste.

If the waste is a mixture of more than one or unlisted waste, enter all of the relevant U.S. EPA Hazardous Waste Number. Six (6) spaces are provided for this on each line. Generators who ship lab packs are required to list separately the hazardous waste number for each waste in such shipments.

Item 8. TAX CODE - Place an “A” or “B” in this box only if one of these two situations is applicable, otherwise leave blank.

A.Enter an “A” if waste has been previously reported to the Department on form “Facility Summary Report - MO 780-0408”. (Not to be confused with the Generator’s Hazardous Waste Summary Report.) This is only applicable to those sites which have been permitted or who have interim status to store hazardous waste longer than the regulatory time limits.

B.Enter a “B” if the waste involved was generated as a result of hazardous waste which must be disposed of as provided by a remedial plan for an abandoned or uncontrolled site under section 260.435-260.550 RSMo or as part of a remedial plan required by sections 260.350-260.434 RSMo.

Item 9. TOTAL AMOUNT OF WASTE - Enter the total quantity of the waste or waste mixture described on this line.

Item 10. UNIT OF MEASURE - Enter the unit of measure code for the quantity of waste described on this line. Units of measure and the appropriate codes are to be used as follows:

UNIT OF MEASURE	CODE
Pounds	. . . . P
Tons (2,000 lbs.)	. . . . T
Kilograms	. . . . K
Metric Tons	. . . . M
Gallons**	. . . . G
Liters*	. . . . L

**If these codes are used, you must provide the specific gravity rounded off to the nearest tenth, of each waste, in Item 11, located directly to the right. If the specific gravity is not provided for a total described as gallons or liters, Missouri Department of Natural Resources will assume the waste’s specific gravity to be 1.5.

Item 11. SPECIFIC GRAVITY - If a volume code is used as described in Item 10 to describe a total quantity, you need to indicate the specific gravity of the waste, otherwise leave blank.

NOTE: Specific gravity is a ratio based on the weight of water - water weighs 8.3 pounds per gallon and has a specific gravity of 1.0.฀ A฀ substance which weighs 12.5 pounds per gallon is 1.5 times heavier than water therefore the specific gravity is 1.5 (1.5 x 8.3 lbs = 12.5 pounds฀ per gallon).฀A substance which weighs 6.6 pounds per gallon weighs 0.8 times that of water (.8 x 8.3 lbs= 6.6 lbs.฀per gallon).

MO 780-1097 (03-14)฀

PAGE 4

ITEM 12. MANAGEMENT METHOD CODE

Management Method codes describe the type of hazardous waste management system used to treat, recover or dispose a hazardous waste. Enter the management method code that was entered on your manifest.

NOTE: If a different handling code applies to different portions of the same waste, use a separate line entry for each portion as shown in the example on page 6.

MANAGEMENT METHOD CODES

		USE THE CODE IN THE
		FAR LEFT COLUMN IF
		YOUR MANIFEST HAS A
		CODE LISTED IN THIS
CODE	DESCRIPTION	COLUMN
1.	RECLAMATION AND RECOVERY
H010	Metals recovery including reporting, smelting, chemical, etc.
H020	Solvents recovery (distillation, extraction, etc.)
	Other recovery or reclamation for reuse including acid regeneration, organics recovery, etc.
H039	(specify in comments)
	Energy recovery at this site – used a fuel (includes on-site fuel blending before energy
H050	recovery; report only this code)
	Fuel blending prior to energy recovery to another site (waste generated either on site or
H061	received from off-site)

2.DESTRUCTION OR TREATMENT PRIOR TO DISPOSAL AT ANOTHER SITE

	Incineration – thermal destruction other than use as a fuel (includes any preparation prior to
H040	burning)
	Chemical treatment (reduction/destruction/oxidation/precipitation); do not include immediate
	treatment in an exempt wastewater treatment unit with discharge to a NPDES-POTW
H070	(unless required by state)	H071, H073, H075, H077
	Biological treatment with or without participation (includes any preparation or final processes
H081	for consolidation of residuals)
	Physical treatment only
	(absorption/adsorption/separation/stripping/dewatering); do not include immediate treatment
	in an exempt wastewater treatment unit with discharge to a NPDES-POTW (unless required	H082, H083, H101, H103,
H100	by state)	H123, H124
	Stabilization prior to land disposal at another site
H110	(encapsulation/stabilization/fixation)	H111, H112
	Combination of chemical, biological, and/or physical treatment; do not include immediate
	treatment in an exempt wastewater treatment unit with discharge to a NPDES-POTW
H120	(unless required by state)
H121	Neutralization only (no other treatment)
	Evaporation (as the major component of treatment; not reportable as H070, H081, H100 or
H122	H120)
H129	Other treatment that does not include onsite disposal (specify in comments)

3.DISPOSAL – SEE NOTE BELOW CODES

H131	Land treatment or application (to include any prior treatment and/or stabilization)
	Landfill or surface impoundment that will be closed as landfill (to include prior treatment
H132	and/or stabilization)
	Deepwell or underground injection (with or without treatment; this waste was counted as
H134	hazardous waste)
H135	Discharge to sewer/POTW or NPDES (with prior storage – with or without treatment)

If these codes are used, and the waste was rendered non-hazardous prior to being placed into the ground, indicate the type of treatment that was used to render the waste non-hazardous in the comment section. If the waste was still hazardous when it was placed into the ground, you may leave the comment section blank. Failure to indicate that a waste was rendered non-hazardous prior to being placed into the ground can result in your company being assessed a land disposal fee that you would not otherwise owe.

4.TRANSFER OFF SITE

The site receiving this waste stored/bulked and transferred the waste with no treatment or recovery (H010-H129), fuel blending (H061), or disposal (H131-H135)

H141 at the receiving site.

*If these codes are used then you must specifically describe the process method used to treat, store, or dispose the identified waste by line number in the comment section as shown in the following example:

MO 780-1097 (03-14)

PAGE 5

If different management method apply to portions of the same waste, use a separate line entry for each portion as shown in the following example.

EXAMPLE:

	SECTION H - WASTE IDENTIFICATION
L	6.						7.						8.	9.	10.	11.		12.
I	DESCRIPTION OF WASTE												TAX		UNIT		MANAGEMENT
N	SHIPPED TO THE			EPA HAZARDOUS									CODE	TOTAL AMOUNT	OF	SPECIFIC		METHOD
E	FACILITY LISTED ABOVE			WASTE NUMBER									(SEE INST.)	OF WASTE	MEAS.	GRAVITY		CODE
1	Waste gasoline and kerosene mixture	D		0		0		1						14923	p
	used in cleaning engine parts															•	H	0	2		0
2
																•
3	Waste gasoline and kerosene mixture	D		0		0		1						1523	p
	used in cleaning engine parts.															•	H	0	6		1
4
																•

SECTION I: TRANSPORTATION SERVICES UTILIZED

Item 13. COMPANY NAME - List the name for each transporter whose services were used for shipments identified on this page.

Item 14. U.S.EPA ID NUMBER - Enter the U.S. EPA ID number for each transporter whose services were used for shipments identified on this page.

SECTION J: COMMENTS

Item 15. COMMENTS - This space may be used to explain, clarify or continue any entry. If used, enter a cross reference to the appropriate section number. If additional space is needed, attach a piece of paper.