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2. Facility Information
4. Report Date*
5. Facility Name*
7. Facility Street Address*
9. City*
10. State*
11. Zip Code*
13. Name of Person Completing Report Form*
14. Email Address*
18. Date
20. Date of Discharge*
21. Discharge Expected to be Greater than 100 Kilograms/Month?*
    -- Select One --No, discharge of hazardous waste less than 100 kilograms per monthYes, discharge of hazardous waste greater than 100 kilograms per month
23. List Hazardous Constituents Contained in Discharge
25. Provide the Mass and Concentration of Hazardous Constituents Discharged During the Month
27. List the Mass and Concentration of Hazardous Constituents Expected to be Discharged During Next 12 Months
31. Waste Reduction
33. I Certify that a Program is in Place to Reduce the Volume and Toxicity of Hazardous Wastes Generated to the Degree Determined to be Economically Practical*

    1. Yes
    2. No
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field