DTSC Form 1004 "Oil Shipment Certification" - California

What Is Form DTSC1004?

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

Form Details:

  • Released on September 1, 1991;
  • The latest edition provided by the California Department of Toxic Substances Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DTSC1004 by clicking the link below or browse more documents and templates provided by the California Department of Toxic Substances Control.

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Download DTSC Form 1004 "Oil Shipment Certification" - California

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State of California – Environmental Protection Agency
Department of Toxic Substances Control
OIL SHIPMENT CERTIFICATION
Pursuant to Sections 25250.1(e) and 25250.18, Chapter 6.5, Division 20, Health and Safety Code, this form must
be maintained with each shipment of recycled oil or exempt oil from the recycling facility or generator to the
shipment’s destination. Use of this form fulfills this requirement. This form or a copy of this form must be kept for
three years by the person certifying the shipment and by the transporter. These forms are subject to audit and
verification by the Department and the California Integrated Waste Management Board.
Instructions to complete this form are on the reverse. Please print or type.
1. SHIPMENT
Cross Reference to Laboratory Analysis Data: ______________ Quantity of Oil Shipped: __________________
Date of Shipment ____________________________ Invoice/Bill of Lading Number:______________________
2. RECYCLING FACILITY/GENERATOR
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
3. TRANSPORTER
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
4. RECEIVING LOCATION (If more than one location, use space on reverse of this form.)
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
5. CERTIFICATION (Check one box)
Recycling Facility
Generator
I hereby declare under penalty of perjury that the oil in this shipment has been tested and is in compliance with
the applicable standards and requirements of Article 13, Chapter 6.5 of Division 20, Health and Safety Code.
Print/Type Name: _____________________________________________________________________________
Title: _______________________________________________________________________________________
Signature: ________________________________________________________
Date: ___________________
DTSC 1004 (9/91)
(formerly DHS 8365)
State of California – Environmental Protection Agency
Department of Toxic Substances Control
OIL SHIPMENT CERTIFICATION
Pursuant to Sections 25250.1(e) and 25250.18, Chapter 6.5, Division 20, Health and Safety Code, this form must
be maintained with each shipment of recycled oil or exempt oil from the recycling facility or generator to the
shipment’s destination. Use of this form fulfills this requirement. This form or a copy of this form must be kept for
three years by the person certifying the shipment and by the transporter. These forms are subject to audit and
verification by the Department and the California Integrated Waste Management Board.
Instructions to complete this form are on the reverse. Please print or type.
1. SHIPMENT
Cross Reference to Laboratory Analysis Data: ______________ Quantity of Oil Shipped: __________________
Date of Shipment ____________________________ Invoice/Bill of Lading Number:______________________
2. RECYCLING FACILITY/GENERATOR
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
3. TRANSPORTER
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
4. RECEIVING LOCATION (If more than one location, use space on reverse of this form.)
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
5. CERTIFICATION (Check one box)
Recycling Facility
Generator
I hereby declare under penalty of perjury that the oil in this shipment has been tested and is in compliance with
the applicable standards and requirements of Article 13, Chapter 6.5 of Division 20, Health and Safety Code.
Print/Type Name: _____________________________________________________________________________
Title: _______________________________________________________________________________________
Signature: ________________________________________________________
Date: ___________________
DTSC 1004 (9/91)
(formerly DHS 8365)
INSTRUCTIONS
Item 1.
Enter a cross reference to the laboratory analysis data used to certify the oil, the quantity of oil being
transferred, the date the shipment leaves the recycling facility or generator, and the identifying number
from the shipping papers.
Item 2.
Enter the name, address, telephone number, and contact of either the recycling facility or generator
corresponding to the box checked in item 5.
Item 3.
Enter the names, addresses, and telephone numbers of all transporters transporting this shipment until the
destination listed in item 4 is reached, or until the shipment is outside California.
If more than two
transporters are used to complete this shipment, attaché an additional DTSC 1004 form, completing only
item 3 on the additional form.
Item 4.
Enter the name, address, contact, and telephone number of the receiving location. If more than one
location will receive the oil in this shipment, complete item 4 below.
Item 5.
The recycling facility operator or the generator is to sign, date, and check the appropriate box in this
section.
You may use this form as a master for photocopying purposes.
If you wish to order certification forms, or if you have any questions, please write or call:
Department of Toxic Substances Control
Alternative Technology Division
P.O. Box 806
Sacramento, California 95812-0806
(916) 324-1807
4. RECEIVING LOCATION (If more than one location, use space on reverse of this form.)
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
Name: ______________________________________________
Address: ____________________________________________
Contact: _____________________________
____________________________________________________
Telephone Number: ____________________
DTSC 1004 (9/91)
(formerly DHS 8365)
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