Form MO780-1097 "Generator's Hazardous Waste Summary Report" - Missouri

What Is Form MO780-1097?

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 July 1, 2020;
  • 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 MO780-1097 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 MO780-1097 "Generator's Hazardous Waste Summary Report" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
GENERATOR’S MISSOURI ID NUMBER (6 characters)
WASTE MANAGEMENT PROGRAM
GENERATOR’S HAZARDOUS WASTE
SUMMARY REPORT – PART 1
GENERATOR’S EPA ID NUMBER (12 characters)
ATTENTION: If any of your registration
GENERATOR’S NAME
information has changed, other than the
contact info listed below, you MUST complete
SITE STREET ADDRESS
the Notification of Regulated Waste Activity
form (MO 780-1164) to make these changes.
CITY
STATE
ZIP CODE
SECTION A – REPORT IDENTIFICATION (Complete Item 1 or Item 2, NOT BOTH)
ANNUAL
QUARTERLY
PAGE
1.
2.
3.
9/30/______ (YYYY)
12/31/______(YYYY)
7/1/______ (YYYY) TO 6/30/______ (YYYY)
1 of ____
3/31/______ (YYYY)
6/30/_______(YYYY)
SECTION B – CONTACT INFORMATION
4. CONTACT PERSON (NAME)
HAS CHANGED
TITLE
HAS CHANGED
5. MAILING ADDRESS
HAS CHANGED
TELEPHONE NUMBER WITH AREA CODE
HAS CHANGED
6. CITY
STATE
ZIP CODE
E-MAIL
HAS CHANGED
SECTION C – STATUS OF WASTE GENERATED
7. NUMBER OF SHIPMENTS MADE. Enter the number of
8. REPORTABLE QUANTITY NOT GENERATED. Sign
9. REPORTABLE QUANTITY GENERATED BUT NOT
shipments made this reporting period. If greater than zero,
certification and transmit to the department. (DO NOT
SHIPPED OFF-SITE THIS QUARTER. Sign certification
complete Part 2, sign the certification and transmit to the
COMPLETE PART 2.)
and transmit to the department. (DO NOT COMPLETE
department. If zero, check Item 10 or Item 11, whichever is
PART 2.)
appropriate.
SECTION D – COMMENTS
10.
SECTION E – CERTIFICATION STATEMENT
PRINT NAME
SIGNATURE
DATE
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 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.
Mail completed copy to: MISSOURI DEPARTMENT OF NATURAL RESOURCES
WASTE MANAGEMENT PROGRAM
P.O. BOX 176
JEFFERSON CITY, MO 65102-0176
MANIFEST SUMMARY REPORT
DNR-HWG-11
MO 780-1097 (07-20)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
GENERATOR’S MISSOURI ID NUMBER (6 characters)
WASTE MANAGEMENT PROGRAM
GENERATOR’S HAZARDOUS WASTE
SUMMARY REPORT – PART 1
GENERATOR’S EPA ID NUMBER (12 characters)
ATTENTION: If any of your registration
GENERATOR’S NAME
information has changed, other than the
contact info listed below, you MUST complete
SITE STREET ADDRESS
the Notification of Regulated Waste Activity
form (MO 780-1164) to make these changes.
CITY
STATE
ZIP CODE
SECTION A – REPORT IDENTIFICATION (Complete Item 1 or Item 2, NOT BOTH)
ANNUAL
QUARTERLY
PAGE
1.
2.
3.
9/30/______ (YYYY)
12/31/______(YYYY)
7/1/______ (YYYY) TO 6/30/______ (YYYY)
1 of ____
3/31/______ (YYYY)
6/30/_______(YYYY)
SECTION B – CONTACT INFORMATION
4. CONTACT PERSON (NAME)
HAS CHANGED
TITLE
HAS CHANGED
5. MAILING ADDRESS
HAS CHANGED
TELEPHONE NUMBER WITH AREA CODE
HAS CHANGED
6. CITY
STATE
ZIP CODE
E-MAIL
HAS CHANGED
SECTION C – STATUS OF WASTE GENERATED
7. NUMBER OF SHIPMENTS MADE. Enter the number of
8. REPORTABLE QUANTITY NOT GENERATED. Sign
9. REPORTABLE QUANTITY GENERATED BUT NOT
shipments made this reporting period. If greater than zero,
certification and transmit to the department. (DO NOT
SHIPPED OFF-SITE THIS QUARTER. Sign certification
complete Part 2, sign the certification and transmit to the
COMPLETE PART 2.)
and transmit to the department. (DO NOT COMPLETE
department. If zero, check Item 10 or Item 11, whichever is
PART 2.)
appropriate.
SECTION D – COMMENTS
10.
SECTION E – CERTIFICATION STATEMENT
PRINT NAME
SIGNATURE
DATE
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 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.
Mail completed copy to: MISSOURI DEPARTMENT OF NATURAL RESOURCES
WASTE MANAGEMENT PROGRAM
P.O. BOX 176
JEFFERSON CITY, MO 65102-0176
MANIFEST SUMMARY REPORT
DNR-HWG-11
MO 780-1097 (07-20)
GENERATOR’S MISSOURI ID NUMBER (6 characters)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
WASTE MANAGEMENT PROGRAM
GENERATOR’S HAZARDOUS WASTE
GENERATOR’S EPA ID NUMBER (12 characters)
SUMMARY REPORT – PART 2
SECTION F – REPORT IDENTIFICATION (AS SHOWN ON PART 1)
ATTENTION: Summarize all shipments made to
1. QUARTERLY – for the period ending
2. PAGE
the Hazardous Waste Management facilities in
Section G below. Additional pages are required
9/30/______ (YYYY)
12/31/______(YYYY)
for each off-site management facility listed
.
of ____
3/31/______ (YYYY)
6/30/_______(YYYY)
SECTION G – FACILITY IDENTIFICATION
3. FACILITY NAME (NAME OF OFF-SITE LOCATION WHERE WASTE WAS DELIVERED)
4. FACILITY’S EPA ID NUMBER (12 characters)
5. FACILITY SITE ADDRESS
CITY
STATE
ZIP CODE
SECTION H – WASTE IDENTIFICATION
6.
7.
8.
9.
10.
11.
12.
L
I
DECRIPTION OF WASTE
EPA HAZARDOUS
TAX
TOTAL AMOUNT
UNIT
SPECIFIC
MANAGEMENT
N
SHIPPED TO THE
WASTE NUMBER
CODE
OF WASTE
OF
GRAVITY
METHOD
FACILITY LISTED ABOVE
(SEE
MEAS.
CODE
E
INST.)
1.
2.
3.
4.
5.
6.
SECTION I – TRANSPORTATION SERVICES UTILIZED
13. COMPANY NAME
14. U.S. EPA ID NUMBER (12 characters)
a.
b.
c.
SECTION J – COMMENTS
15.
MANIFEST SUMMARY REPORT
DNR-HWG-11
MO 780-1097 (07-20)
GENERAL
INSTRUCTIONS FOR THE
GENERATOR’S HAZARDOUS WASTE SUMMARY REPORT
DNR HWG-11
INTRODUCTION
1. All registered generators must report to the Missouri 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 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 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.
Fluorescent lamps may be handled as a universal waste. Fluorescent 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 that begins July 1 and ends June 30 of the following year.
1st quarter begins July 1 and ends Sept. 30
2nd quarter begins Oct. 1 and ends Dec. 31
3rd quarter begins Jan. 1 and ends March 31
4th quarter begins April 1 and ends June 30
7. Reports are due within 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, Waste Management Program, P.O. Box 176, Jefferson City, MO 65102, or call 573-751-3176.
PAGE 1
MO 780-1097 (07-20)
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
Provide the Generator’s Missouri ID Number (6 characters) in the space provided in the upper right hand corner of the form.
Please provide the Generator’s EPA ID number (12 characters) in the space provided in the upper right hand corner of the form.
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 that 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 Sept. 30; Oct. 1 to Dec. 31; Jan. 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: CONTACT INFORMATION
Item 4. CONTACT PERSON’S NAME - Enter the name of the contact person for your company. Also provide the Title of the contact
person. Please indicate if this information has changed from previous submissions.
Item 5/6. MAILING ADDRESS - Enter the street and number or P.O. Box number, city, state, and zip code where the U.S. Postal
Service delivers your facility’s mail. Then enter the phone number and e-mail address of the contact person.
SECTION C: STATUS OF WASTE GENERATED
Item 7. 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 8. 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 9. 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.
MO 780-1097
(07-20)
PAGE 2
SECTION D: COMMENTS
Item 10. COMMENTS: Enter any comments that 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 THE
GENERATOR’S HAZARDOUS WASTE SUMMARY REPORT
DNR HWG-11
Check or provide the Generator’s Missouri ID Number (6 characters) in the space provided in the upper right hand corner of the
form. This data may have auto-filled from the previous page.
NOTE: If you will require additional Part 2 pages in your submission, an “ADD PAGE” button is provided at
the top center of the page. Additional pages must be added BEFORE additional information (other than the
pre-populated EPA or Missouri Generator Number) is filled out on your first Part 2 page, or it will populate any
information provided to any added pages. These pages will add at the end of the document, following the
instructions. You may delete the instruction pages from your document prior to submission
.
Check or provide the Generator’s EPA ID number (12 characters) in the space provided in the upper right hand corner of the form.
This data may have auto-filled from the previous page.
SECTION F: REPORT IDENTIFICATION
Item 1. QUARTER – for the period ending - Check the appropriate box identifying 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 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 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) where the waste was delivered.
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 that best describes the waste.
MO 780-1097 (07-20)
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