Form EPA Form 7720-12 EPA Form 7720-12 PCB Transformer Registration

USEPA

United States
Environmental Protection Agency
Washington, DC 20460

Form Approved
OMB No. 2070-0112

PCB TRANSFORMER REGISTRATION
For Official Use Only

Return To:
Fibers & Organics Branch (7404T)
Office of Pollution Prevention & Toxics
U.S. Environmental Protection Agency
1200 Pennsylvania Ave., N.W.
Washington, DC 20460-0001
1. Company Name

Address

Contact Name & Phone #

2. a. Location of PCB Transformer(s) - Location #1

2. a. Location of PCB Transformer(s) - Location #2

b. No. of Transformers and wt. (kg):

b. No. of Transformers and wt. (kg):

c. Any transformers containing flammable dielectric fluid: Yes or No

c. Any transformers containing flammable dielectric fluid: Yes or No

2. a. Location of PCB Transformer(s) - Location #3

2. a. Location of PCB Transformer(s) - Location #4

b. No. of Transformers and wt. (kg):

b. No. of Transformers and wt. (kg):

c. Any transformers containing flammable dielectric fluid: Yes or No

c. Any transformers containing flammable dielectric fluid: Yes or No

7. Certification

Under civil and criminal penalties of law for the making or submission of false or fraudulent statements
or representations (18 U.S.C. 1001 and 15 U.S.C. 2615), I certify that the information contained in or
accompanying this document is true, accurate, and complete. As to the identified section(s) of this
document for which I cannot personally verify truth and accuracy, I certify as a company official having
supervisory responsibility for the persons who, acting under my direct instructions, made the verification
that this information is true, accurate, and complete.
Signature

Name and Official Title (Type of Print)

Date Signed

Paperwork Reduction Act Notice

The annual public reporting burden for this collection of information is estimated to average 0.57 hours per
response. This estimate includes time for reading instructions, searching existing data sources,
gathering and maintaining the needed data, and completing and re viewing collection of information.
Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden to: Director, Collections Strategy Division, U.S.
Environmental Protection Agency (mail code 2822), 1200 Pennsylvania Ave., N.W., Washington, D.C.
20460-0001. Include the OMB number identified above in any correspondence. Do not send the completed
form to this address. The actual information or form should be submitted in accordance with the instructions
accompanying the form, or as specified in the corresponding reg ulations.
EPA Form 7720-12 (06/02)