DEP 7072 ff Revised 2007 Pageof

Commonwealth of Kentucky

2012 Hazardous Waste Annual Report

FORM 3 – Waste Received From Off Site

Equivalent to EPA Form WR

EPA ID Number --- Agency Interest Number
Site Name (Exactly as on Registration)
Waste
1 /

Waste Description (See instructions.) Check one: Liquid Solid

(1) (General)
(2) (Manifest)
EPA
Hazardous Waste Code(s)
/ State Hazardous Waste Code
(if applicable)
/ Name of generator from which this waste was received
EPA ID Number of generator from which this waste was received
---
Quantity Received in Report Year
pounds / Enter the value used to convert this waste to pounds
(Leave blank if waste amount is already listed in pounds)
Form Code
W / Is this waste both hazardous and radioactive?
Yes No / Management Method Code
H
Waste
2 /

Waste Description (See instructions.) Check one: Liquid Solid

(1) (General)
(2) (Manifest)
EPA
Hazardous Waste Code(s)
/ State Hazardous Waste Code
(if applicable)
/ Name of generator from which this waste was received
EPA ID Number of generator from which this waste was received
---
Quantity Received in Report Year
pounds / Enter the value used to convert this waste to pounds
(Leave blank if waste amount is already listed in pounds)
Form Code
W / Is this waste both hazardous and radioactive?
Yes No / Management Method Code
H
Waste
3 /

Waste Description (See instructions.) Check one: Liquid Solid

(1) (General)
(2) (Manifest)
EPA
Hazardous Waste Code(s)
/ State Hazardous Waste Code
(if applicable)
/ Name of generator from which this waste was received
EPA ID Number of generator from which this waste was received
---
Quantity Received in Report Year
pounds / Enter the value used to convert this waste to pounds
(Leave blank if waste amount is already listed in pounds)
Form Code
W / Is this waste both hazardous and radioactive?
Yes No / Management Method Code
H

18