(Make any corrections or additions in the shaded areas.)	Page 1 of ____

2021 MONTANA TREATMENT, STORAGE, AND DISPOSAL FACILITY ANNUAL REPORT FORM	State Use Only
RCRAInfo; FRR NRR
CEDARS:
This report is for the calendar year ending December 31, 2021. Please read all instructions carefully. PLEASE TYPE / PRINT	File Name:
PART ONE	GENERAL INFORMATION Mailing Date: January 18, 2022
I.	Regulated Status	At any time during 2021, did this facility treat, store (for greater than accumulation time limits pursuant to 40 CFR 262.34), or dispose of regulated quantities of hazardous waste?	Yes	If YES, fill out Parts One through Three, as appropriate and return to DEQ.
No	If NO, fill out Part One only and return to DEQ.
II.	FACILITY EPA ID #	DEQ Project Manager
III.	FACILITY NAME
IV.	FACILITY LOCATION ADDRESS	Address
City	State
Zip
V.	CONTACT PERSON First | Last
TITLE
TELEPHONE	EXTENSION
MAILING ADDRESS	Address
City	State
Zip
FAX NUMBER
EMAIL
VI.	ALTERNATE CONTACT First | Last
TITLE
TELEPHONE	EXTENSION
EMAIL
VII.	COST ESTIMATES	Regulated Units:	Closure $	Post Closure $
Facility Wide Corrective Action $
VIII.	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 | Last	Signature	Date Signed (mm/dd/yyyy)
Title

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PART TWO	WASTE IDENTIFICATION AND FINAL MANAGEMENT
IX.	Generated On-Site	XI.	Off-Site Generator Name
Check if waste was generated and treated, stored (for greater than accumulation time limits pursuant to 40 CFR 262.34), or disposed at your facility, then enter “NA” in Sections X, XI, and XII.	XII.	Off-Site Generator Address	(Specify generator from whom all wastes listed on this page were received)
(Street or P.O. Box)
X.	Off-Site Generator EPA ID Number	_ _ _ _ _ _ _ _ _ _ _ _
(Enter Generator 12 digit EPA ID No.)	(City or Town)	(State)	(Zip Code)
XIII.	A	B	C	D	E	F
Line #	Description of Waste	EPA Hazardous Waste Codes	Last or Final Management Method	Last or Final Management Location	Amount of Waste	Unit of Measure
Density	lbs/gal sg
On-site Off-site
lbs/gal sg
On-site Off-site
lbs/gal sg
On-site Off-site
lbs/gal sg
On-site Off-site
lbs/gal sg
On-site Off-site
lbs/gal sg
On-site Off-site
lbs/gal sg
On-site Off-site
lbs/gal sg
On-site Off-site
lbs/gal sg
XIV.	COMMENTS:

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PART THREE	TOTAL WASTE IN STORAGE ON DECEMBER 31, 2021
XV.	NO - No Waste was in storage on December 31, 2021 Check this box if NO hazardous waste was in storage at your facility on December 31, 2021.
YES - Waste was in storage on December 31, 2021 Check this box if hazardous waste was in storage at your facility on December 31, 2021, then fill out Section XVI.
XVI.	A	B	C	D	E	F
Line #	Description of Waste	EPA Hazardous Waste Codes	On-Site Storage Process Code	Amount of Waste	Unit of Measure	Year Waste Placed in Storage
S
S
S
S
S
S
S
S
S
XVII.	COMMENTS