Quarterly Hazardous Waste Report
Off-Site Facility Report
/
Quarter & Year
Peel off Name and Address Label from backing and place here.
Note: Any company name, address, and/or contact person changes require
DHEC Form 2701 to be completed
Enter “X” here if no hazardous waste accepted for treatment, storage, disposal, recovery this quarter.
Total amount of Hazardous Waste in Storage
Total amount of Hazardous Waste Received
at the end of this quarter (in pounds).
for this quarter (in pounds).
/
/
MM
DD
YY
Date Received
Generator EPA/DHEC ID#
Description of Waste Received
EPA/DHEC Waste Codes
Manifest Document Number
Form Code
Management Code
Amount (lbs.)
/
/
MM
DD
YY
Date Received
Generator EPA/DHEC ID#
Description of Waste Received
EPA/DHEC Waste Codes
Manifest Document Number
Management Code
Amount (lbs.)
Form Code
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 submitting 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
DHEC 1964 (01/2013)
Page
of
Quarterly Hazardous Waste Report
Off-Site Facility Report
/
Quarter & Year
Peel off Name and Address Label from backing and place here.
Note: Any company name, address, and/or contact person changes require
DHEC Form 2701 to be completed
Enter “X” here if no hazardous waste accepted for treatment, storage, disposal, recovery this quarter.
Total amount of Hazardous Waste in Storage
Total amount of Hazardous Waste Received
at the end of this quarter (in pounds).
for this quarter (in pounds).
/
/
MM
DD
YY
Date Received
Generator EPA/DHEC ID#
Description of Waste Received
EPA/DHEC Waste Codes
Manifest Document Number
Form Code
Management Code
Amount (lbs.)
/
/
MM
DD
YY
Date Received
Generator EPA/DHEC ID#
Description of Waste Received
EPA/DHEC Waste Codes
Manifest Document Number
Management Code
Amount (lbs.)
Form Code
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 submitting 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
DHEC 1964 (01/2013)
Page
of