Laserfiche WebLink
0:/03/04 MON 07:13 FAX 209 463 6045 TEAM CALIPER U00-.) <br />OMB#: 2050-0028 E)pires 1/31/2006 <br />SEND COMPLETED <br />United Sta'fes Environmental Protection Agency <br />FORM TO: <br />The Appropnate State or <br />RCRA SUBTITLE C SITE IDENTIFICATION FORM <br />EPA Regional Office. <br />1. Reason for <br />Reason for Submittal: <br />Submittal <br />im To provide Initial Notification of Regulated Waste Activity (to obtain an EPA ID Number for hazardous <br />(See instructions <br />waste, universal waste, or used oil activities) <br />on page 13.) <br />❑ To provide Subsequent Notification of Regulated Waste Activity (to update site identification information) <br />MARK ALL BOX(ES) <br />❑ As a component of a First RCRA Hazardous Waste Part A Permit Application <br />THAT APPLY <br />❑ As a component of a Revised RCRA Hazardous Waste Part A Permit Application (Amendment #�_) <br />❑ As a component of the Hazardous Waste Report <br />2. Site EPA ID <br />EPA ID Number <br />Number (page 14) <br />I� <br />3. Site Name <br />Name: (y �t3V t L, Does 10 C . <br />(page 14) <br />4. Site Location <br />Street Address: ?j ZS Ctt %CR -X y�A� <br />Information <br />City, Town, or Village: -j �j� <br />State: <br />(page 14) <br />County Name: j tJ �O vl� <br />Zip Code: ClsZp (n <br />5. Site Land Type <br />Site Land Type: Cl Private CU County ❑ District ❑ Federal ❑ Indian XMunicipal U State ❑ Other <br />(page 14) <br />6. North American <br />A. 3 aj(9 3 <br />B. <br />Industry <br />classification <br />C. <br />D. <br />System (NAICS) <br />Code(s) for the Site <br />(page 14) <br />7. Site Mailing <br />Street or P. O. Box: SOAE � I <br />City, Town, or Village: <br />Address <br />(page 15) <br />State: <br />Country: <br />Zip Code: <br />8. Site Contact <br />First Name:j/(�5�� <br />tt�� <br />MI: <br />Last Name: � (o <br />Person <br />(page 15) <br />Phone Number: ��7'v I�� Extension: V� <br />6 <br />Email address: tCUSpL�-Joe � few', <br />D <br />9. Operator and <br />A. Name of Site's Operator: <br />Date Became Operator (mm/dd/yyyy): <br />i d ((O L 1 <br />ID <br />Legal Owner <br />G I Qb <br />I 1 <br />of the Site <br />Operator Type: Private El County ❑ District U Federal :3 Indian ❑ Municipal state L) Other <br />(pages 15 and 16) <br />B. Name of Site's Legal Owner: <br />Date Became Owner (mm/ddlyyyy): <br />U��IV� NK <br />. U �-`T. t,k10(.S <br />. <br />Owner Type: Private ) County ❑ District LJ Federal O Indian ❑ Municipal U State ❑Other <br />Pana 1 of <br />EPA Form 8700-12 (Revised 1/2004) <br />E <br />