SITE INFORMATION AND CORRESPONDENCE

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ar ,lute of Glif,nla—Health and welfare Agency • • ��J L',Toxicesu once l Ser Ices FACILITY HAZARDOUS WASTE REPORT FOR 1988JUL 1989 Part A: General Company Information and Status This report is for the calendar year ending December 31, 1988. Read all instructions carefully bef6Nlf✓r4K1jiWAtVI tenjthis form. Parts I through Vlll of this report form must be completed and returned regardless of facility status. Pl9jRt0Td$ERkJft9vith elite type (12 characters per inch): one character per box. 1. FACILITY EPA I.D. NUMBER 11. FACILITY SIC CODE ICIA]D1018191618111016181 t I� 1 1 1 1 1 1 1 1 1 1 III. COMPANY NAME IE IL ID IO IR IA ID 101 IC IH IE IM II IC IA IL I IC 101 11 IN ICI I I I I I I I I I I I I I I I IV. LOCATION OF FACILITY I1 IS 10 ISI IE1 IC IH IA IR IT IE IRI IW IAIYI I I I I . I I I I I I I I S ree 15 IT It� IC IK IT 10 IN I I I I I I I I 1 1 1 1 1 1 � l 91512 1015 I SCJ city or own State ZIP Code County Code V. FACILITY MAILING ADDRESS (if different from Section IV above.) II I I I I I I I I I I I I I I I I I I I I I I I I I I I I Street, Route Number,or P.o.Box I I I I I I I I I 1 i 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 City or Town State ZIP Code County Code VI. FACILITY CONTACT FOR STATE USE ONLY ID IA IT 1 IFI IS IM IT IT IH I I I I I I I I I I I I I I I I I 1 1 1 Name Logged: IV ITWIF1 IPIRIFISITIDIFINIT1 1 1 1 1 1 1 1 1 1 1 1 1 Title Review: IS 11 In I -16 IS IA I -lo la 19 Iz 1 Area Code Phone Number Entered- VII. This EPA number is only for hazardous waste hauling/transfer station operations. ® No ❑ Yes — Do not complete the remainder of this form. Sign below in Section V1 11, and return this page to Department of Health Services. VIII. l certify under penalty of law that, as the authorized representative, l 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. I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment. A. Please Print: Last Name First Name MI Title SMITH PAT E. VICE PRESIDENT e. Signature Date of signature(month/day/year) l "r 1 7-21-89 IX. FACILITY STATUS: This section is to be completed only by companies which are allowed to treat, store, dispose of, or recycle hazardous waste under ISD or permit or which have applied for a variance for a treatment, Storms,disposal, or recycling facility. N/A NOTE: STATE OF CALIF. REQUIRES STORAGE FACILITY STATUS DUE TO gl POUND OF CONTAMINATION A. Select only one of the following descriptions of hazardous waste handling activities. Select the description which best describes the activities at your facility. IN SOIL. ❑ 1. This facility only treats, stores, disposes of, or recycles hazardous wastes which are generated on site. This facility does not accept hazardous waste from any off-site generators. - ❑ 2. This facility accepts hazardous waste generated off site by affiliated operations of the same business or corporation only. This facility does not accept hazardous waste generated off site on a commercial basis. ' ❑ 3. This facility commercially accepts hazardous waste generated off site. QUESTIONS ARE CONTINUED ON REVERSE SIDE. f DHS 8363 (1/89)