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2540-PM-BWM0395 Rev. 8/2008 Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
FORM U
REQUEST TO PROCESS OR DISPOSE OF RESIDUAL WASTE
| This form must be fully and accurately completed. All required information must be typed or legibly printed in the spaces provided. If additional space is necessary, identify each attached sheet as Form U, reference the item number and identify the date prepared. The date on attached sheets needs to match the date noted below. |
| DEP USE ONLY |
Date Received & General Notes
SECTION A. LANDFILL CLIENT (LANDFILL OR PROCESSING FACILITY OWNER) INFORMATION
| DEP Client ID# |
| DEP Client Type / Code |
Organization Name or Registered Fictitious Name
Community Refuse Service, Inc.
SECTION B. LANDFILL SITE (LANDFILL OR PROCESSING FACILITY) INFORMATION
| DEP Site ID# |
| Site Name |
| Landfill Permit ID# |
| 254520 |
| Cumberland County Landfill |
| 100945 |
| Site Contact Last Name |
| First Name |
| MI |
| Suffix |
| Site Contact Title |
| Site Contact Email Address |
SECTION C. GENERATOR CLIENT (GENERATOR OF THE WASTE) INFORMATION
| Company Name |
| DEP Generator ID# |
| Letterkenny Army Depot |
| n/a |
| Company Contact Last Name |
| First Name |
| MI |
| Suffix |
| Company Mailing Address Line 1 |
| Company Mailing Address Line 2 |
| Company Address Last Line – City |
| State |
| Zip+4 |
| Country |
| Chambersburg |
| PA |
| 17201 |
| USA |
| Company Phone |
| Ext |
| Company Email Address |
| Company Contact Last Name |
| First Name |
| MI |
| Suffix |
| Contact Phone |
| Ext |
| Contact Email Address |
If a Subsidiary, Name of Parent Company
| Is the waste generated at the Company Mailing Address (noted above)? |
| |_| |
| Yes |
| |_| |
| No |
If ‘No’, describe location of waste generation and storage.
SECTION D. WASTE DESCRIPTION
Residual Waste Code Residual Waste Code Description
Amount Unit of Measure Time Frame
| 710 |
| Plant Trash |
| 2500 |
| |_| |
| cu yd |
| |_| |
| gal |
| Annually |
| |_| |
| lb |
| |_| |
| ton |
| |_| |
| One Time |
1. GENERAL PROPERTIES
| a. |
| pH Range |
| to |
| (based on analyses or knowledge) |
| b. |
| Physical State |
| |_| |
| Liquid Waste (EPA Method 9095) |
| |_| |
| Solid (EPA Method 9095) |
| |_| |
| Gas (ambient temperature & pressure) |
| c. |
| Physical Appearance |
| Color |
| arious |
| Odor |
| NO |
| Number of Solid or Liquid Phases of Separation |
| one |
Describe each phase of separation.
n/a
| d. |
| Attached is information from the generator certifying that a hazardous waste determination has been done and that the waste is not hazardous waste as defined in 40 CFR 261, as incorporated by reference at 25 Pa. Code 261a.1. |
| |_| |
| Yes |
| |_| |
| No |
Caution: If ‘No’, the application form is incomplete.
| e. |
| Is the waste treated hazardous waste? |
| |_| |
| Yes |
| |_| |
| No |
If ‘Yes’, list the hazardous waste code(s) that apply to the hazardous waste before treatment.
If ‘Yes’, what treatment option was selected?
What limit was required to be met by the treatment option?
| Provided a copy of the certification required under 40 CFR 268.7(a), as incorporated by reference at 25 Pa. Code 268a.1, that the waste meets all the land disposal restriction requirements, as specified in 40 CFR Part 268, Subpart D (Land Disposal Restrictions-Treatment Standards). |
| |_| |
| Yes |
| |_| |
| No |
| f. |
| Has the waste been delisted as a hazardous waste by DEP or US EPA? |
| |_| |
| Yes |
| |_| |
| No |
| |_| |
| N/A |
| g. |
| Has the waste been accepted for disposal/processing at another Pennsylvania facility? |
| |_| |
| Yes |
| |_| |
| No |
If ‘Yes’, list the facility permit ID number(s).
101100
| h. |
| Has an application for disposal/processing of the waste at another Pennsylvania facility been submitted? |
| |_| |
| Yes |
| |_| |
| No |
If ‘Yes’, list the facility permit ID number(s).
101100
2. ANALYSIS ATTACHMENTS
| a. |
| Has a detailed physical, chemical and radiological characterization of the waste and its leachate been conducted? |
| |_| |
| Yes |
| |_| |
| No |
If ‘No’, provide detailed explanation supporting use of generator knowledge in lieu of actual analysis.
| If ‘Yes’, attached is a description of the waste sampling methods in accordance with the waste sampling plan as required in §271.611(a)(3) or §287.132(a)(3) and the Final Guidance Document on Radioactivity Monitoring at Solid Waste Processing and Disposal Facilities (Document Number 250-3100-001). |
| |_| |
| Yes |
| |_| |
| No |
| b. |
| Laboratory Accreditation Number |
3. PROCESS DESCRIPTION & SCHEMATIC ATTACHMENTS
| a. |
| Attached is a detailed description of the manufacturing and/or pollution control processes producing the waste. |
| |_| |
| Yes |
| |_| |
| No |
If ‘No’, provide explanation.
| b. |
| Attached is a schematic of the manufacturing and/or pollution control processes producing the waste. |
| |_| |
| Yes |
| |_| |
| No |
If ‘No’, provide explanation.
| c. |
| Attached is the substantiation for a confidentiality claim (if portions of the information submitted are confidential). |
| |_| |
| Yes |
| |_| |
| No |
| |_| |
| N/A |
4. CHEMICAL ANALYSIS WAIVER
Categories of residual wastes that qualify for the waiving of chemical analysis by the Department are listed below. Check the appropriate box(es) that match the waste proposed to be accepted for disposal.
| |_| |
| burnt demolition debris |
| |_| |
| carpet scraps |
| |_| |
| cured rubber scrap |
| |_| |
| empty containers (uncontaminated) |
| |_| |
| fabric/cloth/textile/leather wastes (excluding treatment sludges) |
| |_| |
| fiberglass insulation scrap |
| |_| |
| food wastes (excluding treatment sludges) |
| |_| |
| hot drained used oil filters (non-terne plated) |
| |_| |
| metal scrap (excluding powdered grindings or if contaminated with fluids or oils) |
| |_| |
| sawdust (excluding treated wood) |
| |_| |
| shingle scrap |
| |_| |
| waste paper |
| |_| |
| waste plastic (excluding extrusion manufacturing & uncured resins) |
| |_| |
| wood wastes (excluding treated wood) |
All waste types not listed above must be approved in writing in the permit by the Department prior to processing or disposal facility acceptance.
SECTION E. PROPOSED PROCESSING, STORAGE AND/OR DISPOSAL METHOD
| Will any special handling procedures (besides direct disposal) described in the waste acceptance plan, be used when managing the waste? |
| |_| |
| Yes |
| |_| |
| No |
| Is this material re-used for construction or operation of the facility? |
| |_| |
| Yes |
| |_| |
| No |
SECTION F. SOURCE REDUCTION STRATEGY
Form 25R must be completed by the generator and attached to this application unless waived in the instructions to that form.
| Form 25R attached. |
| |_| |
| Yes |
| |_| |
| No |
| |_| |
| Waived |
SECTION G. CERTIFICATION OF PROCESSING OR DISPOSAL FACILITY
I hereby certify that the statements of fact contained therein are true and correct to the best of my knowledge, information and belief. This statement and verification is made subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to un-sworn falsification to authorities.
| Name of Responsible Official |
| Title |
Signature
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