Pollution Prevention Planning

Please fill in the following information.

facility name:
rcra or crk identification number:
site location:
address / city / zip
mailing address:
address / city / zip
facility contact:
name / phone / e-mail

Does your facility(s) generate less than 2,640 lbs/yr of dangerous waste? YES NO

You can verify this by checking your dangerous waste manifests, dangerous waste annual reports, and other facility records. If you generate more than 2,640 lbs/yr of dangerous waste, you must prepare a pollution prevention plan.

List all hazardous substance(s) (HS) you reported to TRI in the last three years.

Enter Year 20____ / Enter Year 20____ / Enter Year 20____
Example: mercury / Example: mercury / Example: mercury

List all permits you have, the agency who issued it, and the reference number.

permit type / issuing agency / permit reference number
Example: NPDES / Ecology-Water Quality / WA-123456-7
ECY 070-439b, December 2013 / 1 / Hazardous Waste and Toxics Reduction Program

Pollution Prevention Planning

facility name

Use a blank page for each hazardous substance you reported. Provide your answers and information following the guidelines and examples found on page 2.

Hazardous substance reported to TRI:
Source of hazardous substance:
Concentration of hazardous substance in source material:

1.  Using the table below, list the total amounts of the basic raw material or fuels that contain this hazardous substance and the hazardous substance used for the last three years. (Specify pounds, tons, gallons, etc.)

Enter Year 20___ / Enter Year 20___ / Enter Year 20___
Total basic raw material used
Total hazardous substance used

2.  What purpose does this hazardous substance serve? Be specific.

3.  What have you done to research alternative basic materials or fuels that do not contain the hazardous substance and how feasible would it be to implement the alternatives?

4.  Describe efforts your company has made to prevent or reduce the release of this hazardous substance to the environment.

ECY 070-439b, December 2013 / 1 / Hazardous Waste and Toxics Reduction Program

Pollution Prevention Planning

facility name

Answer the following questions for each hazardous substance you reported. Provide your information following the guidelines and examples found on page 2.

Hazardous substance reported to TRI:
Source of hazardous substance:
Concentration of hazardous substance in source material:

1.  Using the table below, list the total amounts of the basic raw material or fuels that contain this hazardous substance and the hazardous substance used for the last three years. (Specify pounds, tons, gallons, etc.)

Enter Year 20___ / Enter Year 20___ / Enter Year 20___
Total basic raw material used
Total hazardous substance used

2.  What purpose does this hazardous substance serve? Be specific.

3.  What have you done to research alternative basic materials or fuels that do not contain the hazardous substance and how feasible would it be to implement the alternatives?

4.  Describe any efforts your company has made to prevent or reduce the release of this hazardous substance to the environment.

ECY 070-439b, December 2013 / 1 / Hazardous Waste and Toxics Reduction Program