|
BEFORE COPYING FORM, ATT
<br />OR ENTER:
<br />SITE NAME �� �G/
<br />;H SITE IDENTIFICATION LABEL)
<br />C�
<br />OMB#: 2050-0024 Expires 9/30;92
<br />U.S. ENVIRONMENTAL
<br />PROTECTION AGENCY
<br />1991 Hazardous Waste Report
<br />FORM IDENTIFICATION AND
<br />EPA ID NO.�� �jQ, CERTIFICATION
<br />L 1 --LJ ' c
<br />()
<br />INSTRUCTIONS: Read the etailed instructions beginning on page 6 of the 1991 Hazardous Waste Report booklet before completing this form.
<br />SEC. I
<br />I Site name and location adc ress. Complete items A through H. Check the box ® in items A, C, E, F, G, and H if same as labelf _
<br />SEC. III I Name, title, and telephone
<br />different, enter corrections. If label Is absent, enter information. Instruction page 6
<br />A. PNwprtr+t Last name µ6.. ' -- e. TNN -._......_......._.. Q TaMMtsre �-_.__..._....�•.r...�..-.+..._-._..._..... _.
<br />A. EPA 10 No.
<br />Sarre ss label 13 or —�
<br />yyrr��
<br />11LJ
<br />g,
<br />c? ,,.e
<br />...-..__.,�......-.»-._...._..-•- -
<br />V C C;-, [-4
<br />C. Site/company name
<br />A
<br />la7 . � ; : ❑:,.1 Yes';
<br />O. the site name attwc4rd ritlt tlMe EPA I charged sincege
<br />Same u label ❑ or -�
<br />/1
<br />E1 �`f ( ! /
<br />Enter flee Standard Indu
<br />n P No
<br />E. Street name and number. N not applicable, enter
<br />Same as label ❑_
<br />indlatriw pati bLWng came or other physical location description.
<br />G 1.
<br />ite
<br />activities of the B. MIs
<br />`� n
<br />or
<br />t� -, ta• ':+,-tn;l;1 �t5*•,rctr, r"•+ > ,,fy of �t�aurta '-: - .
<br />A. 'd ' ., t:
<br />F. City, town, 77llage, etc. .. -
<br />Same u label ❑//J'j
<br />..
<br />O. State
<br />SSE
<br />❑
<br />H. Zip Code
<br />Sane as bel U -., d :;,s.aLt b :: a) \ '•. .. _
<br />la
<br />or
<br />',•u•r.rn yraCy f l 1
<br />+,
<br />..reavnllntiga0!U-
<br />V
<br />under penalty Ot
<br />that this document and all attachments were prepared under my direction or supenflalo�11164crordsince With a .
<br />designed to auun
<br />SECIVI
<br />t qualified personnel properly gather and "tuale the Infofma6m eubrflRted. - Based offfli j "iry of fM person
<br />SEC. II
<br />1 Mailing address of site. Instruction
<br />page 6
<br />Oil. 4
<br />A. Is the marling address the sane as the locatlgn address? }S ❑� 1 Yes ( SKIP TO SEC. IllI y �-- -
<br />. ,CJ2 No' GO TO BOX B -"s1 h•; u[:.:. t�.� r`.J>'anttc:.... t-7.ttrk`7►1 to JiJAJ .d
<br />S. Number and street name ofaddress M
<br />-
<br />T//f�a1
<br />C. Cay, tciirn. riiags,, etc.
<br />0. State
<br />E. Zip code
<br />! 1 I
<br />.. I I
<br />-. _ , .:'.4 _ _.:{:: ;. :li• . , ,.:MI � `•u.: ilk .n l .n
<br />SEC. III I Name, title, and telephone
<br />number of the person who should be contacted." questions arise regarding this,hport.. pages,
<br />A. PNwprtr+t Last name µ6.. ' -- e. TNN -._......_......._.. Q TaMMtsre �-_.__..._....�•.r...�..-.+..._-._..._..... _.
<br />�(..(/�
<br />���` �
<br />���
<br />O .•t.A:T*111'�:J ./9'i.r r7Vi7lR7"La�
<br />SEC. IV
<br />Enter flee Standard Indu
<br />Class ficatlon (SIC) Code that describes the principal products, group of profit Eft- pr6ddad safbLittid, 0(—
<br />R Industrydasaiptb?t a the c�mbinad
<br />the services rendered at tit oft's physical location. En (.more than one SIC Code only fro -one
<br />1
<br />ite
<br />activities of the B. MIs
<br />page 7. t j -k;,
<br />1 •r �
<br />t� -, ta• ':+,-tn;l;1 �t5*•,rctr, r"•+ > ,,fy of �t�aurta '-: - .
<br />A. 'd ' ., t:
<br />�• ,� r,f ,a :n '. ! 1 . I lJ
<br />Q r+:., 't'.1.J .0io' 6911 Ytre'4'a :''. t, �::.
<br />D. rM. ^�(J'yJ't .0
<br />u;kaoetictlay;.
<br />',•u•r.rn yraCy f l 1
<br />+,
<br />..reavnllntiga0!U-
<br />V
<br />under penalty Ot
<br />that this document and all attachments were prepared under my direction or supenflalo�11164crordsince With a .
<br />designed to auun
<br />SECIVI
<br />t qualified personnel properly gather and "tuale the Infofma6m eubrflRted. - Based offfli j "iry of fM person
<br />ns who manage system. of, those persons directly responsible for gathering the Information, the Informatlon*Awnitted Is tothe
<br />�.
<br />-ce
<br />my knowledge and
<br />lief.true,,accu.4te and complete. I am aware that Ihers are sotf cans penalties ur1d0(•SpOtl9n 30% d :
<br />Conservati a p.00wryActfor wbmitting false information, Including the possibility of fine and Im wntfor knowing
<br />C,
<br />ns.•.:,
<br />_ _..
<br />A- Phase pone Last narna
<br />R•M Wane AAL a ,L T" - .
<br />!N
<br />Q agnsl `a �
<br />EPAEPA—F� 13ki (FMvM
<br />or..•........-a...�.
<br />�`
<br />��•. ij�`4 y t ,vr��,-etT\�r,til.'��i� �� t•. t,rwdwt(J � �� __7��r���,..�ti `"t► `" (`-
<br />`7 }.(j., r..q rr. .� �. ..Y 11. 5�•: IV*'DS'.:y _..- {A' _ �: •.•.wi •YleQ„ '• t? .J
<br />r, L Y: r4,r7r+0.a*.fFt�. i i„v,
<br />1 •`iNF�I �./4.{�,.�'�P,'.. .•b'`i �. c•i !i",,. Ft
<br />
|