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CME*: Z050-0024 Expires 9!30;92
<br />INSTRUCTIONS: Read the detailed instructions beginning on page 6 of the 1991 Hazardous Waste Report booklet before completing this form
<br />SEC. I I Site name and location add ess. Complete items A through H.
<br />Check the box ® in items A, C. E, F, G , and H if same as label; if
<br />or
<br />Instruction page 6
<br />EEFORE COPYING FORM. ATTA
<br />H SITE IDENTIFICATION ILS�_rl+l►
<br />Sema ass label a 1�
<br />�ii /\
<br />OR ENTER:
<br />D. Has the sna Hama assoc alae wilt lrrs EPA IO (harped arca 19699 2 t Vat
<br />game as label [a or -�
<br />U.S. ENVIRONMENTAL
<br />Resource Conservation and
<br />2 No
<br />E. Street name and nnumoer. It not appllcade, dil Ind Latnal park, binding name Or olner i nysKal location desC ObOM
<br />PROTECTION AGENCY
<br />WESTERN PACIFIC RAILROAD
<br />NOV 0 5
<br />E9
<br />1991 Hazardous Waste Report
<br />CAD981385347
<br />Same as label ®
<br />C. 319nowe
<br />same as al
<br />Same as label p(
<br />MO. GAY vll
<br />IIIIIIIIIIIIIIIIIIIIIIIII�III IIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIII
<br />Ln
<br />1 Mailing address of site. Inst" Liction page 6
<br />ID
<br />A. Is the mailing aoaess me same as lne location
<br />pERMITISER
<br />I ESU�RM
<br />CERT F CA IONND
<br />S. Number and street name or muff" address
<br />s f7
<br />/,
<br />/`//& ! i ,�
<br />INSTRUCTIONS: Read the detailed instructions beginning on page 6 of the 1991 Hazardous Waste Report booklet before completing this form
<br />SEC. I I Site name and location add ess. Complete items A through H.
<br />Check the box ® in items A, C. E, F, G , and H if same as label; if
<br />different, enter corrections. If label is absent, enter information.
<br />Instruction page 6
<br />A. EPA 10 No.- '
<br />19 -� L�
<br />g Co nry _
<br />S
<br />Sema ass label a 1�
<br />�ii /\
<br />C. Sale/company name
<br />D. Has the sna Hama assoc alae wilt lrrs EPA IO (harped arca 19699 2 t Vat
<br />game as label [a or -�
<br />Cl
<br />Resource Conservation and
<br />2 No
<br />E. Street name and nnumoer. It not appllcade, dil Ind Latnal park, binding name Or olner i nysKal location desC ObOM
<br />Same as label 18,J
<br />or -
<br />F. C,tv, town, Iiiage, etc.
<br />p, fTdle
<br />G. State
<br />®
<br />H. Zip Code �p1
<br />Same as label ®
<br />C. 319nowe
<br />same as al
<br />Same as label p(
<br />MO. GAY vll
<br />SEC. II
<br />1 Mailing address of site. Inst" Liction page 6
<br />A. Is the mailing aoaess me same as lne location
<br />redress? t Yes ( SKIP TO SEC. III 1
<br />0 2 No (GO TO BOX 8 1
<br />S. Number and street name or muff" address
<br />s f7
<br />/,
<br />/`//& ! i ,�
<br />-
<br />C C ii
<br />C. Gty, to village, etc.
<br />O. state
<br />E. Zip Code
<br />/C
<br />SEC. III
<br />I Name. title, and telephone umber of the person who should be contacted it questions arise regarding this report. Instruction page 6
<br />A. Please print: Wt name vet name 0,1. I.
<br />H. Tile
<br />C. Trialpnone
<br />activities of the site. Instructi n page 7
<br />A.
<br />Extension zt `
<br />C
<br />0.
<br />f, true, accurate and complete. I am aware that there are significant penalties under Section 3008 of the
<br />SEC. IV
<br />Enter the Standard Industria Classification (SIC) Code that describes the principal products, group of products, produced or distributed, or
<br />SEC. V
<br />the services rendered at the te's physical location. Enter more than one SIC Code only if no one Industry description includes the combined
<br />qualified personnel properly gather and evaluate the Information submitted. Based on my inquiry of the person
<br />activities of the site. Instructi n page 7
<br />A.
<br />tem, or those persons directly responsible for gathering the information, the Information submitted is, to the
<br />C
<br />0.
<br />f, true, accurate and complete. I am aware that there are significant penalties under Section 3008 of the
<br />Resource Conservation and
<br />covery Act for submitting false information, including the possibility of fine and Imprisonment for knowing
<br />ray■ a �r
<br />EPA Form 6700.13NS (Revised 8.91) OVER '->
<br />'I comity under penalty of law t at this document and all attachments were prepared under my direction or supervision in accordance with a
<br />SEC. V
<br />system designed to assure th
<br />qualified personnel properly gather and evaluate the Information submitted. Based on my inquiry of the person
<br />or persons who manage the s
<br />tem, or those persons directly responsible for gathering the information, the Information submitted is, to the
<br />best of my knowledge and bel'
<br />f, true, accurate and complete. I am aware that there are significant penalties under Section 3008 of the
<br />Resource Conservation and
<br />covery Act for submitting false information, including the possibility of fine and Imprisonment for knowing
<br />violations.'
<br />A. Plea" pint: L"t name F rsl name M.I.
<br />p, fTdle
<br />C. 319nowe
<br />kkkkkkkkk
<br />0. ow d "gr"a"m , 124 LZ n t I�/j 2t
<br />MO. GAY vll
<br />ray■ a �r
<br />EPA Form 6700.13NS (Revised 8.91) OVER '->
<br />
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