Form MO780-0651 "Hazardous Waste Generator's Exception Report" - Missouri

What Is Form MO780-0651?

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 October 1, 2011;
  • 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;

Download a fillable version of Form MO780-0651 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 MO780-0651 "Hazardous Waste Generator's Exception Report" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL QUALITY
PO BOX 176
HAZARDOUS WASTE PROGRAM
JEFFERSON CITY, MISSOURI 65102-0176
HAZARDOUS WASTE GENERATOR’S EXCEPTION REPORT
573-751-3176
NOTE: See page 2 for Instructions to complete this form.
IMPORTANT – IF A COMPLETED HAZARDOUS WASTE MANIFEST IS NOT RETURNED BY THE DESIGNATED
WASTE-HANDLING FACILITY WITH 35 DAYS OF THE DATE THE FIRST TRANSPORTER TOOK POSSESSION OF
THE HAZARDOUS WASTE SHIPMENT, THEN THIS FORM MUST BE COMPLETED AND SENT TO THE
DEPARTMENT WITH 45 DAYS OF THE ORIGINAL SHIPMENT DUE DATE. FAILURE TO DO SO MAY RESULT IN
ENFORCEMENT ACTIONS INTITATED BY THE DEPARTMENT.
ORIGINAL SHIPMENT DATE
DATE THIS FORM WAS COMPLETED
1. GENERATOR’S NAME
TELEPHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
U.S. EPA I.D. NUMBER
2. FIRST TRANSPORTER’S NAME (LIST ADDITIONAL TRANSPORTERS ON A SERARATE SHEET
TELEPHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
U.S. EPA I.D. NUMBER
3. DESIGNATED FACILITY NAME
CITY
STATE
ZIP CODE
ADDRESS
TELEPHONE NUMBER
U.S. EPA I.D. NUMBER
4. MANIFEST DOCUMENT NUMBER
5. WASTE IDENTIFICATION
WASTE NAME
EPA WASTE CODE
TOTAL QUANTITY
UNITS OF VOLUME
A.
B.
C.
D.
6. EFFORTS MADE TO TRACE THE WHEREABOUTS OF THE MISSING HAZARDOUS WASTE OR MANIFESTS
7. “I have personally examined and am familiar with the information submitted on this form, and I hereby certify that the information is true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, which includes fine and imprisonment.”
DATE
SIGNATURE
PRINT NAME
*IF APPLICABLE
** SEE REVERSE FOR LIST OF ABBREVIATED CODES.
MO 780-0651 (10-11)
DISTRIBUTION: ORIGINAL – NATURAL RESORUCES
COPY – GENERATOR
PAGE 1 OF 2
MISSOURI DEPARTMENT OF NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL QUALITY
PO BOX 176
HAZARDOUS WASTE PROGRAM
JEFFERSON CITY, MISSOURI 65102-0176
HAZARDOUS WASTE GENERATOR’S EXCEPTION REPORT
573-751-3176
NOTE: See page 2 for Instructions to complete this form.
IMPORTANT – IF A COMPLETED HAZARDOUS WASTE MANIFEST IS NOT RETURNED BY THE DESIGNATED
WASTE-HANDLING FACILITY WITH 35 DAYS OF THE DATE THE FIRST TRANSPORTER TOOK POSSESSION OF
THE HAZARDOUS WASTE SHIPMENT, THEN THIS FORM MUST BE COMPLETED AND SENT TO THE
DEPARTMENT WITH 45 DAYS OF THE ORIGINAL SHIPMENT DUE DATE. FAILURE TO DO SO MAY RESULT IN
ENFORCEMENT ACTIONS INTITATED BY THE DEPARTMENT.
ORIGINAL SHIPMENT DATE
DATE THIS FORM WAS COMPLETED
1. GENERATOR’S NAME
TELEPHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
U.S. EPA I.D. NUMBER
2. FIRST TRANSPORTER’S NAME (LIST ADDITIONAL TRANSPORTERS ON A SERARATE SHEET
TELEPHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
U.S. EPA I.D. NUMBER
3. DESIGNATED FACILITY NAME
CITY
STATE
ZIP CODE
ADDRESS
TELEPHONE NUMBER
U.S. EPA I.D. NUMBER
4. MANIFEST DOCUMENT NUMBER
5. WASTE IDENTIFICATION
WASTE NAME
EPA WASTE CODE
TOTAL QUANTITY
UNITS OF VOLUME
A.
B.
C.
D.
6. EFFORTS MADE TO TRACE THE WHEREABOUTS OF THE MISSING HAZARDOUS WASTE OR MANIFESTS
7. “I have personally examined and am familiar with the information submitted on this form, and I hereby certify that the information is true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, which includes fine and imprisonment.”
DATE
SIGNATURE
PRINT NAME
*IF APPLICABLE
** SEE REVERSE FOR LIST OF ABBREVIATED CODES.
MO 780-0651 (10-11)
DISTRIBUTION: ORIGINAL – NATURAL RESORUCES
COPY – GENERATOR
PAGE 1 OF 2
INSTRUCTIONS FOR COMPLETING THE HAZARDOUS WASTE
GENERATOR’S EXCEPTION REPORT (Form MO 780-0651)
A legible copy of the manifest at issue must accompany this form.
1.
Enter the generator’s company name, telephone, address, and U.S. EPA I.D. number.
2.
Enter the first transporter’s company name, telephone, address, U.S. EPA I.D. number, and USDOT Number. List additional
transporter’s on a separate sheet, then attach to this form.
3.
Enter the designated facility’s company name, telephone, address, and U.S. EPA I.D. number.
4.
Enter the manifest document number.
5.
Enter each waste name appearing on the manifest, EPA Waste Code, Total Quantity, and the Units of Volume per the
following codes:
G – Gallons (liquids only)
P- Pounds
T – Tons
Y – Cubic Yards
L – Liters (liquids only)
K – Kilograms
M – metric Tons (1,000 kg.)
N – Cubic Meters
6.
Enter a statement of the efforts made to trace the missing manifest document. Attach a separate sheet if needed.
7.
Enter the handwritten signature of an authorized person employed by the generator, and the date.
IMPORTANT NOTE: Failure to complete and transmit this information to this department, within regulatory time frames, may
result in enforcement action.
Send to:
Missouri Department of Natural Resources
Hazardous Waste Program
P.O. Box 176
Jefferson City, Missouri 65102-0176
MO 780-0651 (10-11)
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