STATE OF LOUISIANA NOTIFICATION OF HAZARDOUS WASTE ACTIVITY (HW-1) FORM (COMPLIES WITH US EPA’S RCRA SUBTITLE C SITE IDENTIFICATION FORM REQUIREMENTS) Reason for Submittal: Reason for Submittal To provide initial notification (to obtain an EPA ID Number for hazardous universal waste, or used oil activities). To provide subsequent notification (to update site identification information). CHOOSE ONLY ONE or REASON As a component of a RCRA Hazardous Waste Part A Permit Application. PER SUBMITTAL As a component of a Revised RCRA Hazardous Waste Part A Permit Application (Amendment #______________). or As a component of the Hazardous Waste Report. Site met the definition of an LQG in 1 or more months of the reporting year. B. Number of Employees: 2. Site ID Number EPA ID Number: LA AI#: 3. Site Name Legal Name: 4. Site Location Street Address: (PHYSICAL City, Town, or Village: State: LA NOT P.O. BOX or ROUTE) Parish: Zip: Private County/Parish District Federal Site Land 5. Site Land Type Type: Indian Municipal State Other 6. North American A. C. Industry Classification B. D. System (NAICS) Code(s) 7. Site Mailing Address Street Address or P. O. Box: City, Town, or Village: State: Zip Code: Country: 8. Site Contact Person First Name: MI: Last Name: Phone Number ( ) Title: Address: Email: City: State: Zip: 9. Legal Owner and Name of Site's Legal Owner: Operator of the Site Date Became Owner (mm/dd/yyyy): (SEE INSTRUCTIONS) Private County/Parish District Federal Type: Indian Municipal State Other Name of Site's Operator:
STATE OF LOUISIANA NOTIFICATION OF HAZARDOUS WASTE ACTIVITY (HW-1) FORM (COMPLIES WITH US EPA’S RCRA SUBTITLE C SITE IDENTIFICATION FORM REQUIREMENTS) Reason for Submittal CHOOSE ONLY ONE REASON PER SUBMITTAL Reason for Submittal: To provide initial notification (to obtain an EPA ID Number for hazardous universal waste, or used oil activities). To provide subsequent notification (to update site identification information). or As a component of a RCRA Hazardous Waste Part A Permit Application. As a component of a Revised RCRA Hazardous Waste Part A Permit Application (Amendment #______________). or As a component of the Hazardous Waste Report. Site met the definition of an LQG in 1 or more months of the reporting year. B. Number of Employees: 2. Site ID Number EPA ID Number: LA AI#: 3. Site Name Legal Name: 4. Site Location (PHYSICAL P.O. BOX or ROUTE) Street Address: City, Town, or Village: State: LA Parish: Zip: 5. Site Land Type Site Land Type: Private Indian County/Parish Municipal District State Federal Other 6. North American Industry Classification System (NAICS) Code(s) A. C. B. D. 7. Site Mailing Address Street Address or P. O. Box: City, Town, or Village: State: Zip Code: Country: 8. Site Contact Person First Name: MI: Last Name: Phone Number ( ) Title: Address: Email: City: State: Zip: 9. Legal Owner and Operator of the Site (SEE INSTRUCTIONS) Name of Site's Legal Owner: Date Became Owner (mm/dd/yyyy): Type: Private Indian County/Parish Municipal District State Federal Other Name of Site's Operator: NOT
State_of_LA_Haz_Waste_Notif_Form_HW-1.docx