7710-53 PCB Notification of PCB Activity

United States
Environmental Protection Agency
Washington, DC 20460

USEPA

Form Approved OMB No. 2070-0112
Expires 11/30/2022

Notification of PCB Activity
For Official Use Only
Return To:
Document Control Officer (5305P)
Office of Solid Waste
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

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501
et seq. (OMB Control No. 2070-0112). Responses to this collection of information are mandatory (40
CFR 761). An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. The public reporting and
recordkeeping burden for this collection of information is estimated to .57 hours per response. Send
comments on the Agency’s need for this information, the accuracy of the provided burden estimates and
any suggested methods for minimizing respondent burden to the Regulatory Support Division Director,
U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed form to this
address.”
EPA Form
7710-53 (Rev. 3/08)
Previous editions are obsolete.