Quarterly Hazardous Waste Report
Generation and On-Site Treatment, Storage, Disposal, and Recovery
I.
/
Peel off Name and Address Label from backing and place here.
Quarter & Year
Note: Any company name, address, and/or contact person changes require
DHEC Form 2701 to be completed
II.
Enter ‘X’ here if no hazardous waste generated, treated, stored, disposed, recovered, or shipped off site
during this quarter.
III.
IV.
Generated Waste
On-Site Treatment, Storage, Disposal & Recovery
Waste Index
Waste Index
Management Code
Amount T,S,D,R,
Amount Generated
Line #
Line #
On-Site (in lbs)
(in lbs)
V. List below the name, and EPA/DHEC ID# of all the hazardous waste transporters used this quarter.
Transporter EPA/DHEC ID #
Transporter’s Name
Transporter EPA/DHEC ID #
Transporter’s Name
Transporter EPA/DHEC ID #
Transporter’s Name
Transporter EPA/DHEC ID #
Transporter’s Name
VI.
Certification
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that
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 the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submit-
ting false information, including the possibility of fine and imprisonment for knowing violations.
I also certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and I have
selected the method of treatment, storage, or disposal currently available to me which minimized the present and future threat to human health and the environment.
I also certify the out-of-state generators utilizing this facility have programs in place to reduce the volume or quantity and toxicity of waste using a method currently available
which minimizes the present and future threat to human health and the environment.
Signature of Authorized Representative
Print/Type Name & Telephone Number
Date
DHEC 1962 (01/2013)
Page
of
Quarterly Hazardous Waste Report
Generation and On-Site Treatment, Storage, Disposal, and Recovery
I.
/
Peel off Name and Address Label from backing and place here.
Quarter & Year
Note: Any company name, address, and/or contact person changes require
DHEC Form 2701 to be completed
II.
Enter ‘X’ here if no hazardous waste generated, treated, stored, disposed, recovered, or shipped off site
during this quarter.
III.
IV.
Generated Waste
On-Site Treatment, Storage, Disposal & Recovery
Waste Index
Waste Index
Management Code
Amount T,S,D,R,
Amount Generated
Line #
Line #
On-Site (in lbs)
(in lbs)
V. List below the name, and EPA/DHEC ID# of all the hazardous waste transporters used this quarter.
Transporter EPA/DHEC ID #
Transporter’s Name
Transporter EPA/DHEC ID #
Transporter’s Name
Transporter EPA/DHEC ID #
Transporter’s Name
Transporter EPA/DHEC ID #
Transporter’s Name
VI.
Certification
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that
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 the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submit-
ting false information, including the possibility of fine and imprisonment for knowing violations.
I also certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and I have
selected the method of treatment, storage, or disposal currently available to me which minimized the present and future threat to human health and the environment.
I also certify the out-of-state generators utilizing this facility have programs in place to reduce the volume or quantity and toxicity of waste using a method currently available
which minimizes the present and future threat to human health and the environment.
Signature of Authorized Representative
Print/Type Name & Telephone Number
Date
DHEC 1962 (01/2013)
Page
of