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F, . Approved. OMB No. 2050-0028. EV,. 9-30-92 <br />65A N <br />with ELITE type (12 characters per inch) In the unshaded areas only <br />F.ease printt °f tYPe - Date Received 0246 -EPA -OT <br />eiveved <br />please refert 0ijIsfrucnons !V V L111 VG1Ll V r r Wit (For Official use uniy) <br />befofe �i <br />for Fnmg NUit1CAf)M <br />n9� rrH,t,. 1ta EPS+, Regulated Waste <br />omple � <br />information requ4s19d`QCit�V�ty <br />req�urod try law {SeCtI0nd0f0 <br />r, the "3" Wce Consenratton <br />and RacoveryAct!. United States Environmental Protection A enc <br />L. Installation's EPA ID Number (Mark'X' in the appropriate box):' <br />-- - <br />C. nstallatton'4 PA tD Num <br />A: First Notification B. Subsequent NOtifiCaUon <br />(complete item C) C A D 0 0 9 1 1 8 9 1 0 <br />If. Name of Installation (Include company andspecilic site name) + <br />V E R A G E C 0 R I I P O N <br />of Installation (Physical address not P.O- Box or Route Number) <br />111. Location <br />Street <br />3 0 I IA <br />Street(-ed)T <br />_ State ...ZIP Code <br />ot.Town <br />C A 9 5 3 6 6- <br />O <br />R I P N <br />C?ounty.Code Count Name <br />S A N J -IFF U I N <br />IV. Installation Malting Address (See Instrucilonsj <br />Street or P.O. BOX <br />2 3 0 1 1 I N .D I U S T I R I I I A L A V E <br />State <br />'bode, <br />City or Town <br />C A 9 5 3 6 <br />R I P O E <br />V. Installation Contact (Person to be contacted regarding waste activities at site) <br />Name.last lOrst - <br />M <br />F <br />L <br />I <br />N <br />G <br />J <br />O <br />H <br />N <br />Job Title Phone Number (area code and number) <br />P I L I A TN = I N L: E R 2 1 0 1 9 - 5 1 9 9 - 4 1 6 1 <br />VI. installation Contact Address (See Instructions) <br />A. ontact Address B. Street or P.O. Box. <br />Location Mailing <br />X <br />City or Town <br />State Zlp',Code <br />VII. Ownership (See Instructions).: <br />A. Name of Installation's Legal Owner - <br />E <br />B <br />C� <br />U-' <br />r <br />C <br />L' <br />I I <br />I <br />C... <br />E <br />Street, P.O. Boxor Route Number , <br />P I <br />E I <br />A <br />H <br />TTTT- <br />City or Town State <br />ZIP Code - <br />1 <br />1 <br />1 <br />1 <br />'�TT <br />C O <br />C <br />A <br />9 <br />4 <br />1 <br />0 <br />5- <br />B.La4dType <br />C,t7wner Type <br />D.Changeof Owner "(DateChanged) <br />Phone Number area code and number <br />Indicator Month Da Year <br />Yes Yes X No 0 3 0 1 9 1 <br />4 1 <br />5 - <br />5 <br />4 <br />6 <br />4 <br />6 0 <br />0 <br />[:P <br />EPA Form 8700-12 (Rev. 9-92) Previous edition Is obsolete. -1- Continue on reverse <br />