Form MO780-1164 "Notification of Regulated Waste Activity" - Missouri

What Is Form MO780-1164?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-1164 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-1164 "Notification of Regulated Waste Activity" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL REMEDIATION PROGRAM
NOTIFICATION OF REGULATED WASTE ACTIVITY
All new and reactivating registrations require an initial registration fee. Registrations without the correct fee will not be
processed. Checks should be made out to the Missouri Department of Natural Resources. The fee is not required if
only updating information to an existing and active registration. Form must be completed in its entirety, or it will be
returned. Instructions are at the end of this form. Completed form with an original ink signature should be sent to:
Environmental Remediation Program
Environmental Remediation Program
or
1730 E. Elm Street
P.O. Box 176
Jefferson City, MO 65101-4130
Jefferson City, MO 65102-0176
Registration Fee
Schedule
LQG =
$500
SQG =
$150
CESQG = $150
For Office Use Only
1. TYPE OF NOTIFICATION
EPA ID NUMBER
A. NEW NOTIFICATION
MISSOURI ID NUMBER
B. SUBSEQUENT NOTIFICATION
2. NAME OF HANDLER (BUSINESS NAME, SITE NAME OR D.B.A)
3. LOCATION OF HANDLER (PHYSICAL ADDRESS WHERE WASTE IS LOCATED)
STREET
CITY
STATE
ZIP CODE + 4
COUNTY NAME
4. MAILING ADDRESS
SAME AS SITE
STREET
CITY
STATE
ZIP CODE + 4
BILLING ADDRESS:
SAME AS MAILING
STREET
CITY
STATE
ZIP CODE + 4
5. HANDLER CONTACT
ADDRESS SAME AS SITE
ADDRESS SAME AS MAILING
FIRST NAME
MIDDLE NAME
LAST NAME
TITLE
TELEPHONE NUMBER WITH AREA CODE
EXTENSION
ADDRESS
CITY
STATE
ZIP CODE + 4
EMAIL ADDRESS
MO 780-1164 (04-19)
1
MISSOURI DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL REMEDIATION PROGRAM
NOTIFICATION OF REGULATED WASTE ACTIVITY
All new and reactivating registrations require an initial registration fee. Registrations without the correct fee will not be
processed. Checks should be made out to the Missouri Department of Natural Resources. The fee is not required if
only updating information to an existing and active registration. Form must be completed in its entirety, or it will be
returned. Instructions are at the end of this form. Completed form with an original ink signature should be sent to:
Environmental Remediation Program
Environmental Remediation Program
or
1730 E. Elm Street
P.O. Box 176
Jefferson City, MO 65101-4130
Jefferson City, MO 65102-0176
Registration Fee
Schedule
LQG =
$500
SQG =
$150
CESQG = $150
For Office Use Only
1. TYPE OF NOTIFICATION
EPA ID NUMBER
A. NEW NOTIFICATION
MISSOURI ID NUMBER
B. SUBSEQUENT NOTIFICATION
2. NAME OF HANDLER (BUSINESS NAME, SITE NAME OR D.B.A)
3. LOCATION OF HANDLER (PHYSICAL ADDRESS WHERE WASTE IS LOCATED)
STREET
CITY
STATE
ZIP CODE + 4
COUNTY NAME
4. MAILING ADDRESS
SAME AS SITE
STREET
CITY
STATE
ZIP CODE + 4
BILLING ADDRESS:
SAME AS MAILING
STREET
CITY
STATE
ZIP CODE + 4
5. HANDLER CONTACT
ADDRESS SAME AS SITE
ADDRESS SAME AS MAILING
FIRST NAME
MIDDLE NAME
LAST NAME
TITLE
TELEPHONE NUMBER WITH AREA CODE
EXTENSION
ADDRESS
CITY
STATE
ZIP CODE + 4
EMAIL ADDRESS
MO 780-1164 (04-19)
1
6. NORTH AMERICAN INDUSTRY CLASSIFICATION SYSTEM (NAICS) CODE(S)
Visit census.gov/eos/www/naics for NAICS code list.
7. OWNERSHIP
Note: Make copies of this section for multiple ownerships.
NAME OF HANDLER’S LEGAL OWNER (OPERATOR)
STREET, P.O. BOX OR ROUTE NUMBER
CITY
STATE
ZIP CODE + 4
TELEPHONE NUMBER WITH AREA CODE
EXTENSION
DATE BECAME OWNER (MM/DD/YYYY)
INSTALLATION OWNER TYPE - MARK ONE
PRIVATE
COUNTY
DISTRICT
FEDERAL
TRIBAL
MUNICIPAL
STATE
HOSPITAL
OTHER
NAME OF PROPERTY’S LEGAL OWNER
SAME AS HLO
STREET, P.O. BOX OR ROUTE NUMBER
CITY
STATE
ZIP CODE + 4
TELEPHONE NUMBER WITH AREA CODE
EXTENSION
DATE BECAME OWNER (MM/DD/YYYY)
PROPERTY OWNER TYPE (MARK ONE)
PRIVATE
COUNTY
DISTRICT
FEDERAL
TRIBAL
MUNICIPAL
STATE
HOSPITAL
OTHER
8. TYPE OF REGULATED WASTE ACTIVITY
A. HAZARDOUS WASTE ACTIVITIES
Y
N
1. Generator of hazardous waste (If Yes, choose only one and you must enter at least one waste code in section XI).
a. LQG: Greater than 1,000kg (2,220 lbs.) of non-acute hazardous waste or 1kg (2.2 lbs.) of acute hazardous waste
in a calendar month. ($500 if fee required).
b. SQG: Generate 100 to 1,000kg (220-2,220 lbs.) of non-acute hazardous waste at any one time. ($150 if fee
required).
c. CESQG: Generate less than 100kg (220 lbs.) of hazardous waste in a calendar month and never accumulate 100kg
(220 lbs.) or more of hazardous waste at any one time. ($150 if fee required).
Y
N
2. Episodic LQG event (see instructions)
Date of Episodic Event (MM/DD/YYYY) ____/____/________
Y
N
3. United States importer of hazardous waste.
Y
N
4. Mixed waste (hazardous and radioactive) generator.
Y
N
5. Transporter of hazardous waste (If Yes, mark all that apply).
a. Transporter.
b. Transfer Facility (at your site).
Y
N
6. Treater, storer or disposer of hazardous waste (at your site).
Note: A hazardous waste permit is required for this activity.
Check N if you just store your waste within the allowable timeframes prior to shipping off-site for disposal.
Y
N
7. Recycler of hazardous waste (at your site) (If Yes, you must choose only one).
Note: A hazardous waste permit may be required for this activity.
a. Recycler who stores waste prior to recycling
b. Recycler who does not store prior to recycling
MO 780-1164 (04-19)
2
Y
N
8. Exempt boiler or industrial furnace. (If Yes, mark all that apply)
a. Small quantity on-site burner exemption.
b. Smelting, melting and refining furnace exemption.
Y
N
9. Underground injection control.
Y
N
10. Receives hazardous waste from off-site.
Y
N
11. Precious metals reclamation.
Y
N
12. Recognized Trader (If Yes, mark all that apply).
a. Importer
b. Exporter
Y
N
13. Importer/Exporter of Spent Lead-Acid Batteries (SLABS) under 40 CFR Part 266 Subpart G (If Yes, mark all
that apply).
a. Importer
b. Exporter
B. UNIVERSAL WASTE ACTIVITIES
Y
N
1. Large quantity handler of universal waste (accumulate 5,000kg or more). [Refer to Missouri regulations to
determine what is regulated.] Indicate types of universal waste managed or accumulated at your site. (If Yes,
mark all that apply)
a. Batteries
b. Lamps
c. Pesticides
d. Thermostats
Y
N
2. Destination facility for universal waste. Note: A hazardous waste permit may be required for this activity.
C. USED OIL ACTIVITIES
Y
N
1. Used oil transporter (If Yes, mark all that apply)
a. Transporter
b. Transfer facility
Y
N
2. Used oil processor or re-refiner (If Yes, mark all that apply)
a. Processor
b. Re-refine
Y
N
3. Off-specification used oil burner
Y N
4. Used oil fuel marketer (If Yes, mark all that apply)
a. Marketer who directs shipment of off-specification used oil to off-specification used oil burner.
b. Marketer who first claims the used oil meets the specifications.
D. ELIGIBLE ACADEMIC ENTITIES WITH LABORATORIES
Y
N
1. Opting into or currently operating under 40 CFR 262 subpart K (If Yes, mark all that apply)
a. College or University
b. Teaching Hospital that is owned by or has a formal written affiliation with a college or university
c. Non-profit Institute that is owned by or has a formal written affiliation with a college or university
Y
N
2. Withdrawing from 40CFR 262 subpart K
E. NOTIFICATION OF MANAGEMENT OF HAZARDOUS SECONDARY MATERIAL
Y
N
1
. Notifying under 40 CFR 260.42 that management of hazardous secondary material under 40 CFR 260.30, 40
CFR 261.4(a)(23), (24), or (27) is beginning, continuing or stopping (If Yes, the Notification of Hazardous Secondary
Material Activity must be completed).
3
MO 780-1164 (04-19)
F. E-MANIFEST ACTIVITIES
Y
N
1. Broker
2. Receiver
3. Transporter
4. Generator
9. DESCRIPTION OF REGULATED WASTE ACTIVITY (USE ADDITIONAL SHEETS IF NECESSARY)
Waste Codes for Federally Regulated Hazardous Wastes. Please list the waste codes of the federal hazardous wastes
handled at your site. Use an additional page if more spaces are needed for waste codes.
4
MO 780-1164 (04-19)
10. COMMENTS
11. CERTIFICATION
I certify under penalty of law that I have personally examined and 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 fines and imprisonment.
SIGNATURE (ORIGINAL INK REQUIRED)
NAME AND OFFICIAL TITLE (TYPE OR PRINT)
DATE SIGNED
MO 780-1164 (04-19)
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