2018 HAZARDOUS WASTE GENERATOR …

1 FACILITY NAME:This form must be submitted if your facility produces HAZARDOUS WASTE . You must reportANYamount ofhazardous WASTE disposed of from your facility in 2017. Disposal includes HAZARDOUS WASTE picked up by alicensed transporter or taken to a certified collection your facility is in the HAZARDOUS WASTE GENERATOR Program, but no HAZARDOUS WASTE was disposed of in2017, this form is still the amount of HAZARDOUS WASTE your business disposed of during the 2017calendar Tonnage of HazardousWaste Disposed During 2017(calculation guide on back)I hereby certify that this form , including any accompanying statements, is true and correct to the best of myknowledge and :_____Date:_____Print Name:_____Phone:_____INSTRUCTIONS FOR COMPLETING THIS form ON BACKCUPA FACILITY ID.

2 _____Tons2018 HAZARDOUS WASTE GENERATOR reporting FORMCERS ID:EPA ID:NOTE: COMPLETION OF THIS form DOES NOTFULFILL YOUR reporting REQUIREMENTFOR 2018. YOU MUST ALSO SUBMIT ONLINE IN THE CERS WEBSITE: HAZARDOUS WASTE GENERATOR reporting form is due to Contra Costa Health Services HAZARDOUS Materials Programs on or before March1,2018. Facilities may be subject to a 50% late fee if the HAZARDOUS WASTE GENERATOR reporting form is submitted or postmarked after March1, B. WALKER, HEALTH SERVICES DIRECTOR RANDALL L. SAWYER CHIEF ENVIRONMENTAL HEALTH AND HAZARDOUS MATERIALS OFFICER HAZARDOUS MATERIALS PROGRAMS 4585 Pacheco Boulevard, Suite 100 Martinez, California 94553-2233 Ph (925) 335-3200 Fax (925) 646-2073 Contra Costa Alcohol and Other Drugs Abuse Services Contra Costa Emergency Medical Services Contra Costa Environmental Health Contra Costa Health Plan Contra Costa HAZARDOUS Materials Programs Contra Costa Mental Health Contra Costa Public Health Contra Costa Regional Medical Center Contra Costa Health Centers Instructions for Completing and Submitting the HAZARDOUS WASTE GeneratorReporting form ( reporting form )

3 Please read these instructions carefully before completing the reporting form . If you have questions regarding theReporting form , please contact Contra Costa Health Services HAZARDOUS Materials Programs (CCHSHMP) at (925) WASTE is defined as any WASTE that is listed or meets the criteria of toxicity, corrosivity, ignitability, orreactivity as defined by the California Code of Regulations, Title 22, Chapter the reporting Form1. Determine the amount of HAZARDOUS WASTE disposed of by your facility during the 2017 calendar year. Each facilitymust complete a separate reporting form . HAZARDOUS WASTE manifests, consolidated manifests, and/or receipts willprovide you this These guideline conversion factors may be used when calculating tonnage:a) Number of gallons X tons / gallon = Number of tonsb) Number of cubic yards x tons / cubic yard = Number of tonsc) Number of pounds / 2000 pounds = Number of tons3.

4 Enter the total tonnage of HAZARDOUS WASTE disposed of during the 2017calendar year. If no HAZARDOUS WASTE wasdisposed in 2017, enter in signature, print name, date, and phone number. If uploading to CERS (California Environmental ReportingSystem), a signature is not OptionsUpload pdf of the completed reporting form in CERS under 'Miscellaneous State-RequiredDocuments' in the Facility Information submittal element. If there is a previously submitted ReportingForm, click on Discard to remove it before uploading the 2018 reporting form . Type in 'HWGR eporting form ' in the document title section. Click 'Save & Finish'.CERS:FAX:You may fax the completed reporting form to (925) :You may email the completed reporting form may mail the completed reporting form to:Contra Costa Health Services HAZARDOUS Materials Programs4585 Pacheco Blvd.

5 , Suite 100 Martinez CA 94553 Businesses producing ANY amount of HAZARDOUS WASTE must submit the HAZARDOUS WASTE GENERATOR electronic version of the reporting form can be found at: that collect used oil from the public under the CalRecycle Program have special reporting rules. Pleasecall CCHSHMP at (925) 335-3200 and speak with a HAZARDOUS Materials Specialist for more.