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PCB Annual Report Form

This document contains an annual report form for reporting on polychlorinated biphenyls (PCBs). It requests general company information, details on personnel handling PCBs and their training, descriptions of storage facilities and environmental releases, methods of treating and disposing of PCB wastes, and an inventory of PCB equipment and articles. The form collects information necessary to monitor company management of PCBs and ensure proper handling, storage, treatment, and disposal of PCBs and PCB wastes.

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Nimshi Torre
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© © All Rights Reserved
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426 views6 pages

PCB Annual Report Form

This document contains an annual report form for reporting on polychlorinated biphenyls (PCBs). It requests general company information, details on personnel handling PCBs and their training, descriptions of storage facilities and environmental releases, methods of treating and disposing of PCB wastes, and an inventory of PCB equipment and articles. The form collects information necessary to monitor company management of PCBs and ensure proper handling, storage, treatment, and disposal of PCBs and PCB wastes.

Uploaded by

Nimshi Torre
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

ANNEX C

GHEMICAL CONTROL ORDER FOR POLYCHLORINATED BTPHENYLS (PCBs)


ANNUAL REPORT FORM

Repoiting Feriod

A. GCNEML INFORMATION

l. tlaa'tE of Cotnparyr

2. RegisrtmtionNumber:

3. lTat{*a ot8ueiliesrr

E Manufacturing E Sales/Distribution

fl Power Ge6eration E Waste Transport/freatment

E ElectrlcDistrlbution I Oihers

4. Business Address:

5. Nam€ofAuthorizedRepresentative:

Deltllaliarir I

Telephone No.:

Facsimile No.:

t-mail Addressr
B" IIIAIIAGENIENTINFOTIIIIATTO&

l,. Personn€l lnvolved ln the management of PCer, PCB Gquipmer , PCB contaminated cquipment noftPCB
equipment, PCB artlcles, PCB packagin& PCB wastes:

ftumtgr RlEponsibifitiB quaEf,c.tion/Trstrng lnptoyrrent Ststus


"osition/fitlE

. Pcrmanent or contradual

2. ?ersonnelExposurel

Number of Personnel Possible Routes of Entry Durrtlon

3. STORAGE:

Descriptlon of Storate Facllity:

Larietion:

Description oI Storage Procedure:


lnspection and MonltoringFrequenry:

Problems Encountered:

Actions Taken:

SIL15 AIID E}iMRONME}$TAT RELEASES:

Date Details of the lncident ActionsTaken to Actions Taken to Prevent


Mitigate the lncldent Recurrence

I?EATMENT AND DISPOSAL:

Hazardous Waste Generato/s lD:

Treatment and Disposal Method:


Waste Service Provider:

Transporter:

Cohtaat Paisdn :

Address:

Telephone No.:

E-mail Address:

PCB Wastes Treated and Disposed for the Year

Date of Quantity Transport Permlt


Waste Type TreatmenvDlsposal Treated/Dlsposed

Please attach Certificatas of Treatment and Hazardous Wastes Manifest Slips


PCB Wastes:

Sources Total Amount Total Amount Treatment/Disposal


Waste Type
Generated for Treated- Method
the Year Disposed for the
Year

Prepared by:

Signature

Name

Designation

Certified true and correct bY:

Signature

Name

Designation
5. INVENTORY:

Name: Plated PCB Equipment, PCB Contaminated Equipment, Non-PCB Equipment, PCB Articles and Lab€led PCB Packaging:

Equipm6nt/Dcviod lrodel SoflalNo.i Capacity Electicau 0ate Raliremenl Dai€ ll4aintenance Amqrnt & Amount of Sblus Frcqlenry o[ Finding$ R6oommefdations
ArliddPaokagirE lndl,srbl Aoquirod Hbk ry Concent'alion PCB Wasts l orilorhg &
Raling olPoB G€n6rat6d lssoctolls

Plated ReEo-filled, Repaired, Decommissioned of Moved

Status of PCB whether in Seryice, ldle, Unserviceable or ln Storage

Non-Plated PCB Equipment, PCB Contaminated Equipment, l\l,on-PcB Equipment, PCB Articles and Suspected PCB Packaging:

EqupmenU06viod irod6l S6.ialNo-: Capacify Elecfical/ Date Roliroment Dab MBinlenanc6 Amount& Amounlof Status Frequencl of Findings R€commendations
ArliddPaokEOing lndmfial Aoquirod Hislory Concenlrati{oo PCB Wastes lloniloriog &
Raliflg of PCB G6n6rEt6d lnrpecliong

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