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AB# 2050-0024; Expires 11/30/2011 <br />PA Form 8700-12, 8700-13 A/B, 8700-23 (Revised 11/2009) <br />Pagel of _L__ <br />/ <br />LJ <br />'NU <br />�M_ PLETED <br />)RM TO: <br />United States Environmental Protection Agency w 14 2 <br />e Appropriate <br />RCRA SUBTITLE C SITE IDENTIFICATION FORM`' <br />r, <br />ate or Regional <br />five. <br />ENVIRONMENTAL <br />PERMIT/SERVIICES <br />Reason for <br />Reason for Submittal: <br />Submittal <br />❑ To provide an Initial Notification (first time submitting site identification information / to obtain an EPA ID number <br />this location) <br />MARK ALL <br />,for <br />To provide a Subsequent Notification (to update site identification information for this location) <br />BOX(ES) THAT <br />As a component of a First RCRA Hazardous Waste Part A Permit Application <br />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 (If marked, see sub -bullet below) <br />[,Site was a TSD facility and/or generator of >1,000 kg of hazardous waste, >1 kg of acute hazardous waste, or <br />>100 kg of acute hazardous waste spill cleanup in one or more months of the report year (or State equivalent <br />LQG regulations) <br />Site EPA ID <br />EPA ID Number <br />Number <br />Site Name <br />Name: <br />5(�11K <br />6.r ,i\C S <br />Site Location <br />Street Address: <br />InformationCoun <br />Ci ,Town, or//Villa e: b� <br />: q U f ►"1 <br />State: + A <br />Coun : <br />Zip Code: aJ� <br />Site Land Type <br />❑ Private ❑ County ❑ District ❑ Federal ❑ Tribal Municipal ❑ State ❑ Other <br />NAICS Code(s) <br />A 1j 1 <br />1 11 1 CJ 1 <br />C. 1 1 1 1 1 1 <br />Site <br />for the <br />(at least s -digit <br />71 1 8 1 1 <br />D. ( 1 1 1 I 1 1 <br />codes) <br />B. i <br />Site Mailing <br />Street or P.O. Box: 5cuih i <br />Address <br />City, Town, or Village: <br />State: <br />Country: <br />Zip Code: <br />Site Contact <br />First � C..- <br />MI: • <br />Last: 1t✓� <br />Person <br />Title: me_, . <br />!7irboc— <br />Street or P.O. Box: 33 Kzkwi <br />City, Town or Village: <br />State: <br />Count <br />Zi Code: <br />Email: LOtt-0 <br />Phone: , � _ Ext.: <br />_ _ <br />Fax: � <br />Legal Owner <br />A. Name of Site's Legal Owner: / <br />Date <br />and Operator8—District <br />of the Site <br />Owner Type: 11 Private ❑ Count <br />11Federal ❑ Tribal P6 Municipal 11State 13Other <br />Street or P.O. Box: L4 22-6-1 i1 c i - 6A 1, 5 , <br />City,Town, or Village: 15 4_t_ <br />2-2— <br />Phone:2,&r_ 92-12— <br />State: <br />State: <br />Count Pr <br />Zip Code: <br />,j� <br />B. Name of Site's Operator: Lark 5-�-Ua��-d M <br />Date Became <br />IN 7 <br />nr 1C; <br />Operator: <br />Operator <br />❑ Private ❑ County ❑ District ❑ Federal ❑ Tribal ❑ Municipal ❑ State Other <br />Type: <br />PA Form 8700-12, 8700-13 A/B, 8700-23 (Revised 11/2009) <br />Pagel of _L__ <br />