Monthly Waste Receipt Summary Form - TCEQ e-Services

TEXAS COMMISSION ON
ENVIRONMENTAL QUALITY
Registration & Reporting Section
(MC-129)
P.O. Box 13087
Austin, Texas 78711-3087
(512)239-6413
REPORT STATUS
9 Original Summary
9 Revised Summary
9 Supplemental to Summary
9 Unmanifested Waste
MONTHLY WASTE
RECEIPT SUMMARY
(1-5) Receiver’s TCEQ
Solid Waste Registration (SWR) Number
R 1
(6 - 7)
Receiver’s EPA ID
REPORT FOR:
Month Year
(8-9) (10-13)
(14) 9 No shipments received
Treatment/Storage/Disposal (TSD) Facility Name:
You are required to use electronic reporting
(STEERS) unless an exemption has been
granted by the Executive Director. Call 512-
239-6413
Site Address:
Mailing Address:
Street City State Zip
Street City State Zip
This form is to be completed for Unmanifested
and Manifested Hazardous and/ or Class 1 waste
received, except for Class 1 waste which is to be
recycled.
STATE MANIFEST
DOCUMENT NUMBER
STATE GENERATOR’S
ID
US EPA ID (GENERATOR)
If no EPA ID print the Designated Facility Name
WASTE NO.
(TEXAS WASTE CODE)
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
Unmanifested hazardous waste is to be reported within
15 days after receipt. Manifested Class 1 and/or
Hazardous wastes are to be reported by the 25th of the
month following the month of the reporting period.
I certify under penalty of law that I
have personally examined and am
familiar with the information
submitted in this and all attached
documents, and that based on my
inquiry of those individuals
immediately responsible for
obtaining the information, I believe
that the submitted information is
true, accurate and complete.
EPA HAZARDOUS WASTE NUMBER(S)
Four character code starting with D, F, K, P, or, U (i.e., D001)
QUANTITY
Decimals must be in their own box
U
O
M
HANDLING
(SYSTEM TYPE )
CODE
DATE RECEIVED
MMDDYYYY
STATE
TRANSPORTER ID
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89
Quantity Unit of Measure (UOM) (All wastes must be reported in POUNDS (P), KILOGRAMS (K), OR TONS (T)) ü
H
H
H
Itemized explanation of Unmanifested waste, in
accordance with 40 CFR 264.76. (Like item
numbers may be grouped):
Prepared by:
Print Name
Authorized by:
Print Name
Signature Signature
Telephone Date Telephone Date
TCEQ-0113A (Rev. 11/2005) 1 of 2

ADDITIONAL INFORMATION AND INSTRUCTIONS FOR COMPLETING THE MONTHLY WASTE RECEIPT SUMMARY
State Generator’s ID: If the generator is a Texas Facility, then use the ID on the manifest. If the generator is in another state, use the code from this table.
STATE GENERATOR ID CESQG CODE
Alabama D0001 ALCESQG
Alaska D0002 AKCESQG
Arizona D0004 AZCESQG
Arkansas D0005 ARCESQG
California D0006 CACESQG
Colorado D0008 COCESQG
Connecticut D0009 CTCESQG
Delaware D0010 DECESQG
Dist. of Columbia D0011 DCCESQG
Florida D0012 FLCESQG
Georgia D0013 GACESQG
Hawaii D0015 HICESQG
Idaho D0016 IDCESQG
Illinois D0017 ILCESQG
STATE GENERATOR ID CESQG CODE
Indiana D0018 INCESQG
Iowa D0019 IACESQG
Kansas D0020 KSCESQG
Kentucky D0021 KYCESQG
Louisiana D0022 LACESQG
Maine D0023 MECESQG
Maryland D0024 MDCESQG
Massachusetts D0025 MACESQG
Michigan D0026 MICESQG
Minnesota D0027 MNCESQG
Mississippi D0028 MSCESQG
Missouri D0029 MOCESQG
Montana D0030 MTCESQG
Nebraska D0031 NECESQG
STATE GENERATOR ID CESQG CODE
Nevada D0032 NVCESQG
New Hampshire D0033 NHCESQG
New Jersey D0034 NJCESQG
New Mexico D0035 NMCESQG
New York D0036 NYCESQG
North Carolina D0037 NCCESQG
North Dakota D0038 NDCESQG
Ohio D0039 OHCESQG
Oklahoma D0040 OKCESQG
Oregon D0041 ORCESQG
Pennsylvania D0042 PACESQG
Rhode Island D0044 RICESQG
South Carolina D0045 SCCESQG
South Dakota D0046 SDCESQG
STATE GENERATOR ID CESQG CODE
Tennessee D0047 TNCESQG
Utah D0049 UTCESQG
Vermont D0050 VTCESQG
Virginia D0051 VACESQG
Washington D0053 WACESQG
West Virginia D0054 WVCESQG
Wisconsin D0055 WICESQG
Wyoming D0056 WYCESQG
Navajo Nation D0057 NNCESQG
Puerto Rico D0060 PRCESQG
Virgin Island D0066 VICESQG
Guam D0075 GUCESQG
American Samoa D0083 ASCESQG
State Generator’s ID (Out-of-State Foreign Countries)
Mexico
Japan
Canada
England
Spain
Denmark
Germany
F0061
F0062
F0063
F0064
F0065
F0067
F0068
Belgium
Finland
Netherlands
Pacific Is.
Venezuela
France
Malaysia
F0069
F0070
F0071
F0072
F0073
F0076
F0077
Austria
Holland
Hong Kong
Norway
Panama
Greece
Peru
F0078
F0079
F0080
F0081
F0082
F0084
F0085
Brazil
F0086
Off-shore beyond
12 miles F0087
Saudi Arabia F0088
Jamaica
F0089
Italy
F0090
Belize
F0091
Luxembourg
Haiti
Nicaragua
Australia
Sweden
El Salvador
Trinidad/ Tobago
F0092
F0093
F0094
F0095
F0096
F0097
F0098
Taiwan
Cambodia
Bahama Island
Columbia
South Africa
China
India
F0099
F0001
F0002
F0003
F0004
F0005
F0006
Generator’s EPA ID: If the generator has been assigned an EPA ID number, always provide it. If no EPA ID has been assigned, as may be the case with nonhazardous waste, provide the first 12 digits of the company name. If the
generator is a Conditionally Exempt Small Quantity Generator (CESQG), provide the state postal code and the letters “CESQG” in lieu of an EPA ID.
Example: State Generator ID number D0022, Conditionally Exempt Small Quantity Generator from Louisiana, would record the EPA ID number as LACESQG. If the waste is hazardous or nonhazardous and the
generator is from a foreign country, the EPA ID must always be provided by the facility that is accepting responsibility of the waste in Texas known as the - Importer of Record (IOR).
EPA Hazardous Waste Numbers: These numbers ONLY apply to hazardous waste and can be found in 40 Code of Federal Regulations Part 261. If more than four waste codes apply, use the four that best describe the waste.
No Shipments Received: If no hazardous or Class 1 nonhazardous industrial waste was received during the reporting period, mark Box 14 on the front of this form.
HANDLING ( System Type) Codes: For reporting purposes, the Handling code selected should be for the final disposition of the waste, even if the waste is stored prior to disposal.
HANDLING ( SYSTEM TYPE) CODES
H010 Metals recovery including retorting,
smelting, chemical, etc.
H020 Solvents recovery
H039 Other recovery or reclamation for reuse
including acid regeneration recovery, etc.
H040 Incineration - thermal destructiion other than
use as a fuel
H050 Energy recovery at this site - use as fuel
(Includes on-site fuel blending)
H061 Fuel blending prior to energy recovery at
H071
H073
H075
H076
H077
H081
H082
H083
H101
H103
another site
Chemical reduction with or without precipitation
Cyanide destruction with or without precipitation
Chemical oxidation
Wet air oxidation
Other chemical precipitation with or without
pretreatment
Biological treatment with or without precipitation
Adsorption
Air or steam stripping
Sludge treatment
Absorption
H111
H112
H121
H122
H123
H124
H129
H131
H132
Stabilization or chemical fixation prior to disposal
at another site
Macro-encapsulation prior to disposal at another
site
Neutralization only
Evaporation
Settling or clarification
Phase separation
Other treatment
Land treatment or application (to include on-site
treatment and/or stabilization)
Landfill or surface impoundment that will be
H134
H135
H141
closed as landfill (to include on-site
treatment and/or stabilization)
Deepwell or underground injection (with or
without treatment)
Discharge to sewer/POTW or NPDES (with prior
storage - with or without treatment)
Storage, bulking, and/or transfer off-site - no
treatment/recovery, fuel blending, or disposal
at this site
If you have questions on how to fill out this form or about the Industrial and Hazardous Waste Program, please contact us at 512/239-6413. Individuals are entitled to request and review their personal information that the agency
gathers on its forms. They may also have any errors in their information corrected. To review such information, contact us at 512/239-3282.
TCEQ-0113A (Rev. 11/2005) 2 of 2