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OMB#: 2050-0175 Expires 12/31/2003 <br /> MAIL THE <br /> COMPLETED FORM United States Environmental Protection Agency <br /> TO: RCRA SUBTITLE C SITE IDENTIFICATION FORM <br /> The Appropriate State or <br /> EPA Regional Office. <br /> 1. Reason for Submittal Reason for Submittal: <br /> (See Instructions on k#yL To provide Initial Notification of Regulated Waste Activity(to obtain an EPA ID Number for hazardous waste,universal <br /> page 23) waste,or used oil activities). <br /> MARK CORRECT BOX(ES) ❑ To provide Subsequent Notification of Regulated Waste Activity(to update site identification information). <br /> 0 As a component of a First RCRA Hazardous Waste Part A Permit Application. <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 Number EPA ID Number: <br /> (See Instructions on page <br /> 24) <br /> 3.Site Name(See Name: /,,o( �/� <br /> Instructions on page 24) ¢ C / '��j�G r o V r.L(. 7 L V <br /> 4. Site Location Street Address: l� V'*' <br /> Information(See <br /> Instructions on page 24) City,Town,or Village: <br /> ten,,!_ State: (t <br /> County Name: �T��� Zip Code:'Aj <br /> 5.Site Land Type(See Site Land Type:Private 0 County 0 District 0 Federal ❑Indian 0 Municipal 0 State 0 Other <br /> Instructions on page 24) <br /> 6.North American Industry A. B. <br /> Classification System <br /> (NAICS)Code(s)for the <br /> Site(See Instructions on C. D. <br /> page 24) <br /> 7.Site Mailing Address Street or P.O.Box: /(5A'Y.i v�1z�^`'1 P� <br /> (See Instructions on page l <br /> 25) Clty,Town,or Village:ST02 L TOOJ <br /> State: n /1 �llh- <br /> kAl <br /> Country: 0 o , Zip Cotte. �q o <br /> 8.Site Contact Person(See First Name: �It V tdv MI: Last Name: <br /> Instructions on page 25) <br /> Phone Number: 2,M reg Z 7_Q(`y Phone Number Extension: n <br /> .rice "9.Legal Owner and A. Name o S'e'scvL�ega�l Owner L G�j A Date Became Owner(mmlddLlyyyy):/ <br /> Operator of the Site(See K. `L C <br /> instructions on pages 25 to Owner Type: Private 0 County 0 District 0 Federal 0 Indian 0 Municipal 0 State ❑Other <br /> 26) <br /> B. Name of Site' Operator: Date Became Operator(mm/rid/yyyy): <br /> N `Q �O v <br /> Operator Type: Private 0 County 0 District ❑Federal O Indian 0 Municipal 0 Slate ❑Other <br /> f PA Form 8700-12 (Revised 5/2002) Page 1 of 3 <br />