1446.11_Appendix D

United States
Environmental Protection Agency
Washington, DC 20460

USEPA

Form Approved
OMB No. 2070-0112

Notification of PCB Activity
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. Name of Facility

Name of Owner Facility

2. EPA Identification Number (if already assigned under RCRA)

3. Facility Mailing Address (Street or PO Box, City, State, & Zip Code) 4. Location of Facility (No. Street, City, State, & Zip Code)

5. Installation Contact (Name and Title)

Telephone Number (Area Code and Number)

6. Type of PCB Activity (Mark ‘X’ in appropriate box. See Instructions.)
A. Generator w/onsite storage facility

B. Storer (Commercial)

C. Transporter

D. R&D/Treatability

E. Approved Disposer

F. Scrap Metal Recovery Oven/Smelter,
High Efficiency Boilers

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 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, Collection Strategies 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 regulations.
EPA Form 7710-53 (Rev.6/02)
Previous editions are obsolete.

Item-by-Item Instructions
for Completing EPA Form 7710-53
Return completed form to:
Fibers & Organics Branch (7404T)
Office of Pollution Prevention & Toxics
U.S. Environmental Protection Agency
1200 Pennsylvania Ave., N.W.
Washington, DC 20460-0001
Fax: 202-566-0473
No information on the form may be claimed confidential.
Type or print in black ink all items, except Item VII, “Certification.” If you must use additional sheets, indicate clearly the number of the item on
the form to which the information on the separate sheet applies.
Item 1 -- Name of facility: Enter the name of the facility and the name of the owner of the facility.
Item 2 -- EPA identification number (if already assigned under RCRA): Enter the identification number the facility was assigned under the
RCRA hazardous waste notification regulations. If no identification number has been assigned, leave this space blank. A notifier may use their
RCRA Identification number prior to receipt of written verification from EPA once they have confirmed that EPA is in receipt of their PCB
notification form. Confirmation of receipt of the form may be accomplished by submitting it through the U.S. mail -- return receipt requested,
telephoning to confirm receipt of mail or facsimile, commercial overnight carrier’s delivery verification processes, or any other manner in which
the submitter can demonstrate in that the form was received by EPA Headquarters.
Items 3 and 4 -- Facility mailing address and location: Complete Items III and IV. Please note that the address you giv e in Item IV, “Location
of Facility,” must be a physical address, not a post office box or route number. If the mailing address and physical location are the same, you may
enter “Same” in Item IV. If the facility is a mobile incinerator, you may enter “mobile” in Item IV, and provide the mailing address for the
installation contact in Item III.
Item 5 -- Installation contact: Enter the name, title, and business telephone number of the person who should be contacted regarding information
submitted on this form.
Item 6 -- Type of PCB activity: Mark the appropriate box(es) to show which PCB activities are taking place at this facility.
A. Generator with onsite storage facility: You are a generator with an onsite storage facility under this notification requirement if you
are a user, owner, or processor of PCBs or PCB items and you maintain your own storage facilities subject to 40 CFR 761.65(b) or (c)(7)
for PCBs. If you are a generator with an onsite storage facility, mark an “X” in this box.
B. Commercial Storer: You are a commercial storer if you own or operate a storage facility which is subject to the storage facility
standards of 40 CFR 761.65(b) or (c)(7), and which engages in off-site storage activities involving the PCB wastes generated by others.
Most commercial storers of PCB waste perform waste storage services in exchange for a fee or other compensation, but the receipt of
compensation is not necessary for your storage facility to qualify as a commercial storer of PCB wastes generated by others. See
definition of commercial storer in 40 CFR 761.3. If you are a commercial storer, mark an “X” in this box.
C. Transporter: If you move PCBs by air, rail, highway, or water, then mark an “X” in this box.
D. R&D/Treatability: If you are engaged in conducting R&D into PCB disposal technologies and cannot accept waste on a
commercial scale, mark an “X” in this box. You should also check this box if you conduct treatability studies even though you may
have marked the “Approved Disposer” box.
E. Approved Disposer: If you currently hold a valid EPA permit to dispose of PCBs in concentrations exceeding 50 ppm in a landfill,
through alternative technology or incineration, mark an “X” in this box.
F. Scrap Metal Recovery Oven/Smelter, High Efficiency Boilers: If you operate a device to dispose of PCBs, or if you dispose of PCBs
in compliance with Section 761.71 (i.e., high efficiency boilers) or Section 761.72 (i.e., scrap metal recovery oven/smelter), mark an “X”
in this box.
Item 7 -- Certification: This certification must be signed by the owner, operator, or an authorized representative of the facility. An “authorized
representative” is a person responsible for the overall operation of the facility (i.e., a plant manager or superintendent, or a person of equal
responsibility). All notifications must include this certification to be complete.

EPA Form 7710-53 Reverse (Rev.6/02)