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2021 MONTANA LARGE QUANTITY HAZARDOUS WASTE (HW) GENERATOR BIENNIAL REPORT	State Use Only	Inspector:
RCRAInfo NRR
This report is for the calendar year ending December 31, 2021. Please read all instructions in the 2021 Hazardous Waste Report Instructions Booklet before making any entries on the form. PLEASE TYPE / PRINT	CEDARS
PART ONE	Generator Information (See Instructions)	Mailing Date: January 18, 2022
I	REASON FOR SUBMITTAL	☒Component of the Hazardous Waste Report ☐Site was a TSD facility and/or generator of ≥ 1,000 kg of HW, > 1 kg of acute HW, or > 100 kg of acute HW spill cleanup in one or more months of 2021. ☐Provide Subsequent Notification (to update site information)	2021 REGISTERED STATUS
II	EPA ID # / DEQ AREA
III	SITE NAME
IV	CURRENT REGULATED WASTE ACTIVITIES (as of December 31, 2021)	☐ LQG ☐ SQG ☐ CESQG ☐ Short Term/One-Time ☐ Non-Handler ☐ Out of Business ☐ Importer of HW ☐ Mixed Waste Generator ☐ HW Transporter ☐ Transfer Facility ☐ Treater, Storer, or Disposer of HW ☐ Recycler of HW ☐ Small Quantity On-Site Burner Exemption ☐ Smelting, Melting & Refining Furnace Exemption ☐ Underground Injection Control ☐ Receives HW from Off-site	☐ Large Quantity Handler of Universal Waste (UW) Types of UW Accumulated/Managed: ☐ Batteries ☐ Lamps ☐ Pesticides ☐ Mercury containing equipment ☐ Destination Facility for Universal Waste	☐ Used Oil (UO) Transporter ☐ UO Transfer Facility ☐ UO Processor ☐ UO Re-refiner ☐ Off-Specification UO Burner ☐ Marketer Who Directs Shipment of Off-Specification UO to Off-Specification UO Burner ☐ Marketer Who First Claims the UO Meets the Specifications
V	LAND TYPE	☐ Private ☐ County ☐ District ☐ Federal ☐ Tribal ☐ Municipal ☐ State ☐ Other
VI	NAICS
VII	SITE LOCATION ADDRESS	Address
City	State
Zip
VIII	SITE MAILING ADDRESS	Address
City	State
Zip

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IX	CONTACT PERSON First | MI | Last
TITLE
TELEPHONE	EXTENSION
MAILING ADDRESS	Address
City	State
Zip
FAX NUMBER	EMAIL
ALTERNATE CONTACT First | MI | Last
TITLE
TELEPHONE	EXTENSION
EMAIL
X	LEGAL OWNER Business or First & Last Name
TYPE	☐ Private ☐ County ☐ District ☐ Federal ☐ Tribal ☐ Municipal ☐ State ☐ Other
MAILING ADDRESS	Address
City	State
Zip
TELEPHONE	DATE BECAME OWNER
XI	OPERATOR Business or First & Last Name
TYPE	☐ Private ☐ County ☐ District ☐ Federal ☐ Tribal ☐ Municipal ☐ State ☐ Other
DATE BECAME OPERATOR
XII	COMMENTS
XIII	CERTIFICATION	I certify under penalty of law that this document and all attachments were prepared under my direction or supervision according to a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. (40 CFR 270.11).
(Please Type or Print)
Name First | MI | Last	Signature	Date Signed (mm/dd/yyyy)
Title

Revised 2021	An electronic reporting form, in Adobe format, is available at the DEQ Hazardous Waste website: https://deq.mt.gov/twr/assistance

Paper Size: Legal

EPA ID NUMBER: MTR000211987 GENERATOR NAME: RELLC REMEDIATION P66 HELENA TERMINAL	Page ____ of ____
PART TWO – Waste Identification (See Instructions) (Please make copies of this sheet for additional pages)
A	B	C	D	E	F	G	*H	I	J	K	L
Line #	Is this Remediation Waste? Place ‘X’ in box if Yes	Description of Waste	EPA Hazardous Waste Codes (D001, D002…)	Source Code (G _ _ )	Form Code (W _ _ _)	Quantity Generated	Unit of Measure	Waste Minimization Code (see Instructions, page 5)	On-Site Process	Receiving Facility (R) EPA ID Number (#)	Off-site Management Method (H _ _ _)	Quantity Shipped
Management Method for Code G25	*Enter Density Only for G and CY	Management Method (H _ _ _)	Quantity
☐	Choose an item.	Choose an item.	System 1	System 1	R 1 #
Density: Choose an item.	System 2	System 2	R 2 #
R 3 #
☐	Choose an item.	Choose an item.	System 1	System 1	R 1 #
Density: Choose an item.	System 2	System 2	R 2 #
R 3 #
☐	Choose an item.	Choose an item.	System 1	System 1	R 1 #
Density: Choose an item.	System 2	System 2	R 2 #
R 3 #
☐	Choose an item.	Choose an item.	System 1	System 1	R 1 #
Density: Choose an item.	System 2	System 2	R 2 #
R 3 #
☐	Choose an item.	Choose an item.	System 1	System 1	R 1 #
Density: Choose an item.	System 2	System 2	R 2 #
R 3 #
Comments

Revised 2021

* Complete Column I if any of this waste that was generated at this facility was treated, disposed, and/or recycled on-site.

EPA ID NUMBER: MTR000211987 GENERATOR NAME: RELLC REMEDIATION P66 HELENA TERMINAL	Page ____ of ____
PART THREE – Waste Received From Off-Site (See Instructions) (Please make copies of this sheet for additional pages)
A	B	C	D	E	F	G
Line #	Description of Waste	EPA Hazardous Waste Codes (D001, D002…)	Off-site Handler EPA ID Number	Quantity Received in 2021	Unit of Measure	Form Code (W_ _ _)	Management Method Code (H _ _ _)
*Enter Density Only for G and CY
Choose an item.
Density: Choose an item.
Choose an item.
Density: Choose an item.
Choose an item.
Density: Choose an item.
Choose an item.
Density: Choose an item.
Choose an item.
Density: Choose an item.
Choose an item.
Density: Choose an item.
Comments

Revised 2021