Attachment 5a - Facility Profile Sheet.pdf

Attachment 5a

FACILITY PROFILE SHEET

1. Facility Name: _________________________________________________________________

2. Facility Address:

3. Facility Telephone Number: __________________________ FAX:___________________________

4. Facility Representative(s): __________________________________________________________

Telephone Number : _________________________________ EMAIL: _________________________

5. Principal Owner(s): __________________________________________________________

6. DRMS Facility BOSS ID # _____________________ (Provide # if facility has previously been approved by

DRMS)

7. For all of the permits, authorizations, and licenses that authorize the facility to store, treat, recycle, or dispose hazardous waste the following information is required: The permitting authority’s name and address; the permit number, the permit expiration date; wastes authorized by the permit using the European Waste Codes (EWCs) and a description of the treatment processes authorized.

Disposal/Treatment Permitting Authority Permit Number Expiration EWC and Treatment Process Description

8. For each waste that will be processed through the facility identify the waste stream, by CLIN, and the treatment process that will be used with the European Council Directive 91/156/EEC Annex II Codes.

Processed Waste (CLIN) 91 / 156 / EEC Annex II Code

If additional space for CLIN information is required, use same format on additional pages.