Form DTSC1471 "Annual Report for E-Waste Handling and Recycling Activity" - California

What Is Form DTSC1471?

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 June 23, 2011;
  • 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 printable version of Form DTSC1471 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 Form DTSC1471 "Annual Report for E-Waste Handling and Recycling Activity" - California

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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Annual Report for e-waste Handling and Recycling Activity
Each location that collected more than 220 lbs of e-waste (electronic devices, CRTs, and/or CRT glass) in
one calendar year must submit this annual report to DTSC by February 1 of the next calendar year.
Handlers and Generators must fill out “Handler” portions of the Annual Report form. Recyclers must fill
out the whole Annual Report form.
Universal Waste Handlers may accept and accumulate e-wastes from offsite sources, remove batteries and ink cartridges
from electronic devices (22 CCR Section 66273.71), and remove CRTs from CRT devices (22 CCR Section 66273.72(b)).
Handlers may not treat or alter e-wastes in any other way.
Universal Waste Generators cannot accept e-waste from offsite, but must submit this annual report if more than 11,000
lbs of e-wastes were generated in the last calendar year.
Universal Waste Handlers who Treat (Recyclers) must submit an annual report if they treat any electronic devices and/or
CRT. This includes any activities such as dismantling electronic devices, removing yokes from CRTs, treating or breaking
CRT glass, and/or treating printed circuit boards (22 CCR Sections 66273.72(c) and 66273.73 (a) and (b).
All section numbers are found in Title 22 of the California Code of Regulations (abbreviated 22 CCR)
Section 1: Business information [22 CCR Sections 66273.32(d) and 66273.74(b)] (Handlers and Recyclers)
Reporting Year:
Check one:
Handler
Generator
Recycler
Facility ID # (Optional. Found in your online reporting account, not CEW ID number):
Business name:
Telephone number: (
)
Mailing address:
City:
County:
State:
Zip Code:
Contact person’s name:
Contact telephone number: (
)
Contact email address (optional):
EPA/State ID number:
Physical address (if different from mailing address):
City:
County:
State:
Zip Code:
For recyclers only [22 CCR section 66273.74(b)]:
Facility Description (warehouse, parking lot, shed):
Number of days operated this year:
Name and Mailing address of the owner/operator:
City, State, Zip Code:
DTSC 1471 (06/23/11)
Page 1 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Annual Report for e-waste Handling and Recycling Activity
Each location that collected more than 220 lbs of e-waste (electronic devices, CRTs, and/or CRT glass) in
one calendar year must submit this annual report to DTSC by February 1 of the next calendar year.
Handlers and Generators must fill out “Handler” portions of the Annual Report form. Recyclers must fill
out the whole Annual Report form.
Universal Waste Handlers may accept and accumulate e-wastes from offsite sources, remove batteries and ink cartridges
from electronic devices (22 CCR Section 66273.71), and remove CRTs from CRT devices (22 CCR Section 66273.72(b)).
Handlers may not treat or alter e-wastes in any other way.
Universal Waste Generators cannot accept e-waste from offsite, but must submit this annual report if more than 11,000
lbs of e-wastes were generated in the last calendar year.
Universal Waste Handlers who Treat (Recyclers) must submit an annual report if they treat any electronic devices and/or
CRT. This includes any activities such as dismantling electronic devices, removing yokes from CRTs, treating or breaking
CRT glass, and/or treating printed circuit boards (22 CCR Sections 66273.72(c) and 66273.73 (a) and (b).
All section numbers are found in Title 22 of the California Code of Regulations (abbreviated 22 CCR)
Section 1: Business information [22 CCR Sections 66273.32(d) and 66273.74(b)] (Handlers and Recyclers)
Reporting Year:
Check one:
Handler
Generator
Recycler
Facility ID # (Optional. Found in your online reporting account, not CEW ID number):
Business name:
Telephone number: (
)
Mailing address:
City:
County:
State:
Zip Code:
Contact person’s name:
Contact telephone number: (
)
Contact email address (optional):
EPA/State ID number:
Physical address (if different from mailing address):
City:
County:
State:
Zip Code:
For recyclers only [22 CCR section 66273.74(b)]:
Facility Description (warehouse, parking lot, shed):
Number of days operated this year:
Name and Mailing address of the owner/operator:
City, State, Zip Code:
DTSC 1471 (06/23/11)
Page 1 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Section 2: Handling activity and total quantity information [22 CCR section 66273.32(d)] (Handlers and Recyclers)
Types of materials handled/received
bare CRTs
CRT glass
CRT devices
portable DVD players with LCD monitors
LCD monitors
Laptops with LCD monitors
plasma televisions
LCD televisions
computers
microwaves
VCRs
printers
cellphones
telephones
radios
small consumer electronics
large consumer electronics
Total quantities handled/received
# of units or
weight
electronic devices (excluding CRT devices)
pounds
CRT devices
=
pounds ÷
pounds/unit*
CRTs
=
pounds ÷
pounds/unit*
CRT glass
pounds
For recyclers only [22 CCR section 66273.74(b)]:
Treatment information: Check any of the appropriate boxes
Bare CRT treatment
Yoke removal
Physical treatment (e.g., break CRT glass)
Physical separation
Use pinpoint torch/hot wire
Electronic device types dismantled
portable DVD players with LCD monitors
LCD monitors
Laptops with LCD monitors
plasma televisions
LCD televisions
computers
microwaves
VCRs
printers
cellphones
telephones
radios
small consumer electronics
large consumer electronics
List the electronic devices or CRTs treated using the following methods:
Physical treatment (e.g., size reduction):
Did this activity generate hazardous waste?
Yes
No
Physical separation:
Did this activity generate hazardous waste?
Yes
No
Sampling, ashing, ball-milling:
Total quantities treated
# of units or
weight
electronic devices (excluding CRT devices)
pounds
CRT devices
=
pounds ÷
pounds/unit*
CRTs
=
pounds ÷
pounds/unit*
* You must provide the average weight of one device (for example, 50 lbs per CRT device or 25 lbs per CRT)
DTSC 1471 (06/23/11)
Page 2 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Section 3: Destination information [22 CCR Sections 66273.32(d) and 66273.74(b)] (Handlers and Recyclers)
Include additional pages if necessary. Information entered here does not substitute for an export notification.
Destination #1 and quantities shipped to this destination
Name:
Street address:
City, State, Country, Zip:
telephone number :
The quantities shipped to this location:
# of units
or
weight
electronic devices (excluding CRT devices)
pounds
CRT devices
=
pounds ÷
pounds/unit*
CRTs
=
pounds ÷
pounds/unit*
CRT glass (received not generated)
pounds
For Recyclers only– Residuals generated from treatment activity
universal waste (batteries, lamps)
pounds
scrap metal/printed circuit boards
pounds
yokes
pounds
CRT glass
pounds
CRT glass sent for:
Glass manufacturing
Primary smelting
Secondary smelting
Destination #2 and quantities shipped to this destination
Name:
Street address:
City, State, Country, Zip:
telephone number :
The quantities shipped to this location:
# of units
or
weight
electronic devices (excluding CRT devices)
pounds
CRT devices
=
pounds ÷
pounds/unit*
CRTs
=
pounds ÷
pounds/unit*
CRT glass (received not generated)
pounds
For Recyclers only– Residuals generated from treatment activity
universal waste (batteries, lamps)
pounds
scrap metal/printed circuit boards
pounds
yokes
pounds
CRT glass
pounds
CRT glass sent for:
Glass manufacturing
Primary smelting
Secondary smelting
* You must provide the average weight of one device (for example, 50 lbs per CRT device or 25 lbs per CRT)
DTSC 1471 (11/04/10)
Page 3 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Destination #3
Name:
Street address:
City, State, Country, Zip:
telephone number :
The quantities shipped to this location:
# of units
or
weight
electronic devices (excluding CRT devices)
pounds
CRT devices
=
pounds ÷
pounds/unit*
CRTs
=
pounds ÷
pounds/unit*
CRT glass
pounds
For Recyclers only– Residuals generated from treatment activity
universal waste (batteries, lamps)
pounds
scrap metal/printed circuit boards
pounds
yokes
pounds
CRT glass
pounds
CRT glass sent for:
Glass manufacturing
Primary smelting
Secondary smelting
* You must provide the average weight of one device (for example, 50 lbs per CRT device or 25 lbs per CRT)
Section 4. Signed certification:
For Handlers (optional): Based on my inquiry of those persons directly responsible for gathering the information, the
information submitted is, to be the best of our knowledge, true, accurate, and complete.
Name of report preparer
Signature of report preparer
Date
For recyclers:
I certify under penalty of the law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure the qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible
for gathering the information, the information submitted is, to be the best of our knowledge and belief, true, accurate, and
complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations. [22 CCR Sections 66273.74 (d) and 66270.11(d)]
Name of report preparer
Title of report preparer
Signature of report preparer
Date
Hardcopy notifications must be submitted to DTSC by certified mail, return receipt request.
MAIL TO: Department of Toxic Substances Control
Universal Waste Notification and Reporting Staff
P.O. BOX 806
Sacramento, CA 95812-0806
Attention: Universal Waste Handling Activities
DTSC 1471 (11/04/10)
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