90 Day-Final Form - Ohio Epa printable pdf download

State of Ohio Environmental Protection Agency

Cessation of Regulated Operations Program

Regulated Substance & Equipment Removal (90 Day-Final Form)

Where to Send the Completed Form:

Date: ____/____/____

County where facility is located: ________________

Send Originals to:

1.0

Facility Identification

Ohio EPA-DMWM

Reporting, Analysis and Data Management

Facility Name (50 char max)

Lazarus Government Center

P.O. Box 1049

Columbus, Ohio 43216-1049

Street Location (45 char max)

1.1

Send a Copy to:

City (20 char max)

Zip Code

State

Local Emergency Planning Committee

Local Fire Department Having

2.0

Duties of an Owner or Operator

Jurisdiction of the Facility

ORC 3752.06(A)(1) requires you to attach a copy of the most recent emergency and hazardous chemical inventory form with a statement

indicating whether any asbestos-containing materials are present at the facility. If you have not attached this information, please explain

why.

2.1

ORC 3752.06(A)(2) requires you to attach a copy of the current hazardous chemical list, or each MSDS, that you are required to report to

the State Emergency Response Commission after you submitted your most recent emergency hazardous inventory form. If you have not

attached this information, please explain why.

2.2

ORC 3752.06(A)(3) requires you to attach a precise description of where each stationary tank, vat, electrical transformer, and vessel of

any type, that contains or is contaminated with regulated substances and a description of what each item contains or is contaminated

with, if you will be leaving any of these items at the facility. Note: An owner or operator should document stationary items that contain or

are contaminated with regulated substances at the time of cessation of regulated operations. If you have not attached this information,

please explain why. Also, if you need to keep a regulated substance in a stationary item, please identify the item and explain why (e.g.,

2.3

due to local codes, to maintain electrical service).

Describe how the regulated substances from each stationary item that will remain at the facility were transferred, sold or disposed as

required by ORC 3752.06(A)(4). If you need more space, you may attach an explanation/documentation.

2.4

Describe how all the nonstationary equipment and furnishings, nonstationary containers, motor vehicles, rolling stock and debris that

contain or are contaminated with a regulated substance were transferred, sold or disposed, as required by ORC 3752.06(A)(5).

If you need more space, you may attach an explanation/documentation.

(This space for Ohio EPA use only)

2.5

3.0

Certification (Read and Sign After Completing all Sections)

Under civil and criminal penalties of law for the making or submission of false or fraudulent statements or representations, I, the under-

3.1

signed, certify to the best of my knowledge, after making all appropriate inquiries, that the information contained in and accompanying this

document is true, accurate and complete.

Name of the Owner/Operator and Signature

Date Signed:

____/____/____

3.2

(Print)

EPA 0329 (Revised May 2012)

90 Day-Final Form - Ohio Epa

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