HAZARDOUS WASTE GENERATOR TANK SURVEY State Form 52386 (R/9-07) Indiana Department of Environmental Management RCRA ID NUMBER COUNTY: FACILITY NAME: LOCATION ADDRESS: CITY, STATE, ZIP: TANK DESCRIPTION TANK CONTENTS TANK CAPACITY (IN GALLONS): DATE TANK WAS PUT INTO SERVICE: (MM/DD/YYYY) IS THE TANK IN ACTIVE SERVICE? YES NO IS THE TANK UNDERGROUND? CONSTRUCTION MATERIAL: SECONDARY CONTAINMENT: STEEL LINER YES FIBERGLASS PLASTIC OTHER DOUBLEWALL VAULT NO OTHER NONE HAZARDOUS WASTE CODES FIRST NAME: LAST NAME : TITLE : PHONE NUMBER: E-MAIL: I certify under penalty of law that this document and all attachments were prepared under my direction or supervision. Based upon my own knowledge and or inquiry of the person(s) directly responsible for gathering the information reported on this document, the information submitted is, to the best of my knowledge, true, accurate, and complete. SIGNATURE __________________________________________________________________________________________ PAGE OF American LegalNet, Inc. www.FormsWorkflow.com HAZARDOUS WASTE GENERATOR TANK SURVEY INSTRUCTIONS Standards for hazardous waste generator tank management are set forth in 329 IAC 3.1 rule 10 and in Federal regulation 40 CFR Subpart J. In order for IDEM compliance staff to gain an understanding of the number and types of tanks in Indiana which are affected by these rules, we request that you complete this survey. Please copy the form as needed and fill out one form for each hazardous waste storage tank your facility operates. SIGN AND RETURN TO: Indiana Department of Environmental Management Office of Land Quality, Data Services Section 100 North Senate Ave, Room 1101 Indianapolis, IN 46204-2251 QUESTIONS: Nancy Heacox 317-232-7956 nheacox@idem.in.gov American LegalNet, Inc. www.FormsWorkflow.com