Free HAZARDOUS WASTE USED OIL REPORT - Indiana

USED OIL MANAGEMENT REPORT
State Form 52392 (R/9-07) Indiana Department of Environmental Management

COUNTY:

FORM UO

RCRA ID |_ __|_ _|_ _|_ _|_ _|_ _|_ _|_ _|_ _|_ _|_ _|_ _| REPORT YEAR NAME

LOCATION ADDRESS:
A. ENTER THE TOTAL QUANTITY OF USED OIL THAT WAS ACCEPTED FOR PROCESSING OR RE-REFINING

|_ _|_ _|_ _|_ _|_ _|_ _|_ _| . |_ _|

pounds

kilograms

short tons

metric tons

B.
PROCESS # 1

ENTER A NAME AND DESCRIPTION FOR EACH
NAME

PROCESS USED TO PROCESS OR RE-REFINE THE USED OIL.

DESCRIPTION

PROCESS # 2

NAME

DESCRIPTION

PROCESS # 3

NAME

DESCRIPTION

Comments
"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to ensure 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 under IC13-30-6-2 and Section 3008 of the Resource Conservation and Recovery Act for submitting false information, including the possibility of fine and imprisonment for knowing violations."

First Name : Phone # :

Last Name : E-mail :

Title:

Signature __________________________________________________________________ Date______________________
(This form must be printed, signed, and sent in hard copy)

USED OIL MANAGEMENT REPORT
Indiana Rule 329 IAC 13-7-8 requires used oil processors or re-refiners to submit a report by March 1 of every even numbered year that describes their used oil activities for the preceding odd numbered year. Your facility is listed in the Office of Land Quality records as a used oil processor or re-refiner. If this is incorrect, please return the UO form and explain your status in the comments.

DUE DATE This report is due on March 1 of every even numbered year for the activities conducted during the previous odd numbered year. SEND TO Jenny Ranck Dooley Senior Environmental Manager Indiana Department of Environmental Management Office of Land Quality Data Services Section 100 North Senate Avenue, Room 1101 Indianapolis, Indiana 46204 -2251 ASSISTANCE If you have any questions about this report you may contact: Jenny Ranck Dooley [email protected] 317-232-8925