"Printer Compliance Certification Form" - Massachusetts

Printer Compliance Certification Form is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on July 1, 2012;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
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Massachusetts Department of Environmental Protection
Environmental Results Program
Printer Compliance Certification for 20
Facility ID #
A. Facility Information
Complete Year
Field Above
Important: When
Facility Name
Facility SIC Code
Facility ID Number
filling out forms
on the computer,
Facility Street Address
use only the tab
key to move your
cursor - do not
City
State
Zip Code
use the return
key.
Phone Number
Fax Number
Federal Employer Identification Number – FEIN/TIN*
Contact Person Name
Title
Phone Number
Contact Person Email Address
This is a New Facility since last year’s filing deadline of September 15.
Date Opened (mm/dd/yyyy)
This is a Pre-Existing Facility under New Ownership.
New Owner as of Date (mm/dd/yyyy)
DEP USE ONLY
*I certify that the FEIN/TIN above is not a Social Security number.
Date Received
If you don’t have a TIN or have a question about this checkbox, call Marc Cohen at 617-292-5873
(mm/dd/yyyy)
B. Compliance Information
Answer all questions, unless you are directed to skip a question. Do not answer questions that you are
directed to skip.
Hazardous Waste: Questions for all Printers
1. Over the past year did you have any spills or
yes - submit a Spill or Release Report
releases that required reporting to DEP? (Refer
Summary
to Section 1.5. in the Workbook)
no
2. Do you generate hazardous waste? (Refer to
yes
Sections 1.4, 3.1.1 and 3.1.2. in the Workbook)
no - skip to question 16
3. How much hazardous waste did you generate at
your facility during the past 12 months?
Gallons
4a. Indicate your facility’s hazardous waste
VSQG
generator status for hazardous waste by placing
a check next to the appropriate category. (Refer
SQG
to Section 3.1.3. in the Workbook)
LQG
4b. Indicate your facility’s generator status for waste
VSQG
oil if applicable, by placing a check next to the
appropriate category. (Refer to Section 3.1.4. in
SQG
the Workbook)
prcert • Rev. July 2012
Compliance Certification for Printers • Page 1 of 11
Massachusetts Department of Environmental Protection
Environmental Results Program
Printer Compliance Certification for 20
Facility ID #
A. Facility Information
Complete Year
Field Above
Important: When
Facility Name
Facility SIC Code
Facility ID Number
filling out forms
on the computer,
Facility Street Address
use only the tab
key to move your
cursor - do not
City
State
Zip Code
use the return
key.
Phone Number
Fax Number
Federal Employer Identification Number – FEIN/TIN*
Contact Person Name
Title
Phone Number
Contact Person Email Address
This is a New Facility since last year’s filing deadline of September 15.
Date Opened (mm/dd/yyyy)
This is a Pre-Existing Facility under New Ownership.
New Owner as of Date (mm/dd/yyyy)
DEP USE ONLY
*I certify that the FEIN/TIN above is not a Social Security number.
Date Received
If you don’t have a TIN or have a question about this checkbox, call Marc Cohen at 617-292-5873
(mm/dd/yyyy)
B. Compliance Information
Answer all questions, unless you are directed to skip a question. Do not answer questions that you are
directed to skip.
Hazardous Waste: Questions for all Printers
1. Over the past year did you have any spills or
yes - submit a Spill or Release Report
releases that required reporting to DEP? (Refer
Summary
to Section 1.5. in the Workbook)
no
2. Do you generate hazardous waste? (Refer to
yes
Sections 1.4, 3.1.1 and 3.1.2. in the Workbook)
no - skip to question 16
3. How much hazardous waste did you generate at
your facility during the past 12 months?
Gallons
4a. Indicate your facility’s hazardous waste
VSQG
generator status for hazardous waste by placing
a check next to the appropriate category. (Refer
SQG
to Section 3.1.3. in the Workbook)
LQG
4b. Indicate your facility’s generator status for waste
VSQG
oil if applicable, by placing a check next to the
appropriate category. (Refer to Section 3.1.4. in
SQG
the Workbook)
prcert • Rev. July 2012
Compliance Certification for Printers • Page 1 of 11
Massachusetts Department of Environmental Protection
Environmental Results Program
Printer Compliance Certification for 20
Facility ID #
B. Compliance Information (cont.)
5. What is your facility’s hazardous waste
identification number? (Refer to Section 3.1.6. in
Hazardous Waste ID Number (12 Characters)
the Workbook)
6. Do you have appropriate documentation which
yes
shows where hazardous waste is being
shipped? (Refer to Section 3.1.11. in the
no - submit a Return To Compliance Plan
Workbook)
7. Are you shipping your hazardous waste offsite
yes
as frequently as required? (Refer to Section
no - submit a Return To Compliance Plan
3.1.9. in the Workbook)
8. Is all hazardous waste stored in either a
yes
separate, marked off hazardous waste storage
area AND/OR in a workstation accumulation
no - submit a Return To Compliance Plan
area? (Refer to Section 3.1.7., figure 1 in the
Workbook)
9. Are all containers of hazardous waste in good
yes
condition? (Refer to Section 3.1.7., figure 1 in
no - submit a Return to Compliance Plan
the Workbook)
10. Are all containers of hazardous waste labeled as
follows:
10a. As hazardous waste? (Refer to Section
yes
3.1.7. in the Workbook)
no - submit a Return to Compliance Plan
10b. With the name of the waste? (Refer to
yes
Section 3.1.7. in the Workbook)
no - submit a Return to Compliance Plan
10c. With the hazard classification? (Refer to
yes
Section 3.1.7. in the Workbook)
no - submit a Return to Compliance Plan
11. Are all containers of hazardous waste located on
yes
an impervious surface? (Refer to Section 3.1.7.
no - submit a Return to Compliance Plan
figure 1 in the Workbook)
prcert • Rev. July 2012
Compliance Certification for Printers • Page 2 of 11
Massachusetts Department of Environmental Protection
Environmental Results Program
Printer Compliance Certification for 20
Facility ID #
B. Compliance Information (cont.)
12. Are used shop towels stored in closed
yes
containers? (Refer to Section 3.1.10. in the
no
Workbook)
Hazardous Waste
:
Questions for SQG’s and LQG’s (refer to Section 3.1.3 in the Workbook for definitions of SQG and
LQG. See your answer to Question #4 also.) If you are a VSQG, skip to question #16.
13. Do you have a telephone or other
yes
communication system in areas near where
hazardous waste is stored or generated? (Refer
no - submit a Return to Compliance Plan
to Section 3.1.12. in the Workbook)
14. Do you have a sign next to the telephone in
yes
each work area near where hazardous waste is
stored or generated that tells what to do in an
no - submit a Return to Compliance Plan
emergency? (Refer to Section 3.1.12. in the
Workbook and sample sign on page 42 of the
Workbook)
15. Do the hazardous waste containers in the
yes
storage area show the date accumulation
began? (Refer to Section 3.1.7., figure 1 in the
no - submit a Return to Compliance Plan
Workbook)
Industrial Wastewater: Questions for All Printers
16. Do you perform photo processing or plate
yes
imaging that generates a silver bearing waste?
no - Skip to question 18 and do not answer
questions 21-23
16a. Do you ship/haul your untreated silver
yes
bearing waste off-site for recycling?
no
17. Do you have a silver recovery unit?
yes
no – skip to question 18
17a. How many gallons of silver bearing
wastewater did you treat through your silver
Gallons/Year
recovery unit in the past year? (Refer to
Workbook page 47)
prcert • Rev. July 2012
Compliance Certification for Printers • Page 3 of 11
Massachusetts Department of Environmental Protection
Environmental Results Program
Printer Compliance Certification for 20
Facility ID #
B. Compliance Information (cont.)
17b. Is your silver recovery unit directly
yes
connected to your photoprocessing
wastestream?
no
18. Do you discharge or ship industrial wastewater
yes
to the MWRA?
no
Industrial Wastewater:
Questions for printers that discharge or ship industrial wastewater to a POTW outside of the
MWRA service area
Note 1 for 21:
If you answered
yes to question
19. Do you discharge or ship industrial wastewater
yes
16a and you ship
to a POTW (Publicly Owned Treatment Works)
or haul all your
silver-bearing
other than the MWRA?
no – skip to question 24
waste off-site for
recycling then
answer yes to
question 21 and
skip question 22.
20. Do you have a sewer discharge permit from your
yes
local POTW? (Contact your sewer authority to
no – skip to question 21
Note 2 for 21: if
see if you are required to obtain a sewer permit)
you answered
“No” to question
16, skip to
question 24
20a. Are you in compliance with the terms of
yes – skip to question 23
that permit?
no – submit a Return to Compliance Plan
and skip to question 23
21. Are you in compliance with the 2 ppm silver
yes
discharge limit? (Refer to Section 3.2.4. in the
no - submit a Return to Compliance Plan
Workbook)
22. Did you collect the sample within one month
yes
prior to changing the cartridge of your silver
recovery system? (Refer to Section 3.2.6. in the
no - submit a Return to Compliance Plan
Workbook)
23. Do you use a film processor cleaner containing
yes - submit a Return to Compliance Plan
a chromium compound? (Refer to Section 3.2.4.
no
in the Workbook)
prcert • Rev. July 2012
Compliance Certification for Printers • Page 4 of 11
Massachusetts Department of Environmental Protection
Environmental Results Program
Printer Compliance Certification for 20
Facility ID #
B. Compliance Information (cont.)
Industrial Wastewater: Questions for printers on septic systems
24. Are you on a septic system?
yes
no - skip to question 27
25. Do you discharge industrial wastewater to the
yes - You must cease your discharge to the
septic system? (Refer to Section 3.2.2. in the
septic system immediately and submit a Return
Workbook)
to Compliance Plan.
no
26. Do you discharge industrial wastewater to the
yes - You must cease your unpermitted
ground; or surface water (i.e., storm drain, river,
discharge immediately and submit a Return to
lake, or pond) without a permit? (Refer to
Compliance Plan.
Section 3.2.1. in the Workbook)
no
Industrial Wastewater:
Questions for printers that store non-hazardous industrial wastewater
27. Do you store non-hazardous industrial
yes
wastewater in above ground tanks or
containers?
no - skip to question 29
28. Are you in compliance with the requirements for
yes
storing non-hazardous industrial wastewater in
appropriate tanks or containers? (Refer to
no - submit a Return to Compliance Plan
Section 3.2.9. in the Workbook)
Air: Questions for All Printers
29. How much press and/or screen cleaning solution
did you purchase during the past 12 months?
Gallons
30. Indicate your facility’s emission status for volatile
small
organic compounds (VOCs) by placing a check
next to your facility’s category. (Refer to Section
midsize
3.3.1 in the Workbook. Also, refer to page 53 of
large with < 25 tons VOC emissions per year
the Workbook for how to calculate VOC
emissions)
large with > 25 tons VOC emissions per year
prcert • Rev. July 2012
Compliance Certification for Printers • Page 5 of 11
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