Form 7720-12 PCB Transformer Registration Form

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)

Item-by-Item Instructions for Completing EPA Form 7720-12

No information on this form may be claimed as confidential.
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

PCB Transformer means any transformer that contains 500 ppm or greater PCB dielectric. For PCB concentration assumptions
applicable to transformers containing three pounds or more of fluid other than mineral oil, see 40 CFR 761.2. For provisions
permitting reclassification of electrical equipment containing 500 ppm or greater PCBs to PCB-Contaminated Electrical
Equipment, see 40 CFR 761.30(a) and (h).
Type or print in black ink all items, except Item 3, “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

Company Name: Enter the name of the company which owns the equipment.
Address: Enter the street, city, state, and zip code of the company.
Contact Name and Phone Number: Enter the name and business telephone number of the person
who should be contacted regarding information submitted on this form.

Item 2a Location of PCB Transformers: Enter the address (street, city, state, and zip code) where the PCB Transformer(s) is
located. Please note that the address you give must be a physical address, not a P.O. Box. Route numbers are acceptable provided
they include enough specificity to assist emergency response personnel in determining the location of the transformer(s).
Item 2b Number (No.) of Transformers and weight (wt..): Enter the total number of PCB (500 ppm or greater) Transformers
at this location (address) and the total weight (wt..) in kilograms (kg) of the PCB dielectric fluid in the transformer(s).
Item 2c Any transformers containing flammable dielectric fluid: (Response optional) Circle yes or no if you have any
knowledge that there are or are not transformers at this location (address) that contain flammable (see 40 CFR 261.21(a)(1) Characteristics of Ignitability) dielectric fluid.
***Please note this form has been designed to accommodate companies submitting registrations for multiple locations. However,
companies with more than 4 locations may choose to submit an additional form(s) or an attachment(s).
Item VII -- Certification: This certification must be signed by the owner, operator, or an authorized representative of the
transformer owner or operator of the facility or property where the unit is located. 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 responsibil ity).
All notifications must include this certification to be complete.

EPA Form 7720-12 Reverse (06/02)