Form DWM7086 "Request to Be Removed From the Hazardous Waste Handler List" - Kentucky

What Is Form DWM7086?

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

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Kentucky Department for Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DWM7086 by clicking the link below or browse more documents and templates provided by the Kentucky Department for Environmental Protection.

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Download Form DWM7086 "Request to Be Removed From the Hazardous Waste Handler List" - Kentucky

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DWM 7086 (June 2017)
 
 
401 KAR 39:080
Kentucky Department for Environmental Protection
Division of Waste Management
Hazardous Waste Branch
300 Sower Boulevard, Frankfort, KY 40601
(502) 564-6716
Request to be Removed from the Hazardous Waste Handler List
FOR OFFICIAL USE ONLY.
DO NOT WRITE IN THIS SPACE.
Instructions: This form should only be completed by those companies that no longer handle hazardous waste on-site. You should only complete this
form, if you no longer generate, transport, recycle, treat, store, or dispose of hazardous waste. Submittal of this form will render the EPA ID Number
issued for your company invalid for your use. Falsification of information is subject to enforcement action including the possibility of fines and imprison-
ment.
I.
ID Numbers
KY −
EPA ID Number:
Agency Interest (AI) Number:
II.
Company
Name of Company:
Information
Company Location (Provide the actual location (i.e., street address or highway number) of the company being re-
moved from the list):
City:
County:
State:
Zip Code:
Mailing Address (provide the accurate mailing address for future mailings):
City:
State:
Zip Code:
Contact Person:
Title:
Phone Number: (
)
-
III.
Reason for
Explanation: (Mark only one box. Provide a brief written explanation to explain why an EPA ID Number is no longer
needed.)
Removal
Closed
Out of Business
Non-Handler of Hazard-
Other
ous Waste
IV.
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 fine and imprisonment.
A. Signature:
B. Date Signed: (
)
mm/ dd/ yyyy
/
/
C. Typed or Printed Signatory Name:
D. Official Title of Signatory:
DWM 7086 (June 2017)
 
 
401 KAR 39:080
Kentucky Department for Environmental Protection
Division of Waste Management
Hazardous Waste Branch
300 Sower Boulevard, Frankfort, KY 40601
(502) 564-6716
Request to be Removed from the Hazardous Waste Handler List
FOR OFFICIAL USE ONLY.
DO NOT WRITE IN THIS SPACE.
Instructions: This form should only be completed by those companies that no longer handle hazardous waste on-site. You should only complete this
form, if you no longer generate, transport, recycle, treat, store, or dispose of hazardous waste. Submittal of this form will render the EPA ID Number
issued for your company invalid for your use. Falsification of information is subject to enforcement action including the possibility of fines and imprison-
ment.
I.
ID Numbers
KY −
EPA ID Number:
Agency Interest (AI) Number:
II.
Company
Name of Company:
Information
Company Location (Provide the actual location (i.e., street address or highway number) of the company being re-
moved from the list):
City:
County:
State:
Zip Code:
Mailing Address (provide the accurate mailing address for future mailings):
City:
State:
Zip Code:
Contact Person:
Title:
Phone Number: (
)
-
III.
Reason for
Explanation: (Mark only one box. Provide a brief written explanation to explain why an EPA ID Number is no longer
needed.)
Removal
Closed
Out of Business
Non-Handler of Hazard-
Other
ous Waste
IV.
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 fine and imprisonment.
A. Signature:
B. Date Signed: (
)
mm/ dd/ yyyy
/
/
C. Typed or Printed Signatory Name:
D. Official Title of Signatory: