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B <br /> i f onn APProve(1 r)1N$tyn 2050 tib;/nR 02453E PA O r <br /> Please pnnt or type with ELITE type f)2 characters per rich)in the unshaded areas only " <br /> Untied States Environmental Protet:uon Pyency Please refer to the instructions for <br /> Washington,DC 20460 Filmg Notifica(in"before completing <br /> A this form The.,,formationrequested <br /> here is required by law (Section <br /> E PA Notification of Hazardous Waste Activity .7010 or the Resource Conservation <br /> and Recovery Aco. <br /> For Official Use Only <br /> Comments <br /> C I IC ` <br /> Date Received <br /> Installation's EPA ID Number Approved (yr. mo. day/ <br /> C �. <br /> F FFF I I1 <br /> FF <br /> I. Name of Installation <br /> UL JC4 1 t,I �- IL 101nl ( I II I I <br /> II. Installation Mailing Address MW <br /> �/_ Street or P O Box <br /> 3 ' 'V 3[13LL[Ud,1;i1 d <br /> City or Town State ZIP C de <br /> 4 I 110 �_ Iii ) q5 � 5 <br /> III. Location of Installation <br /> Street or Route Number <br /> 5 <br /> City or Town State ZIP Code <br /> I <br /> 6 <br /> IV. Installation Contact 01 0 <br /> Name and Title last. first. andlob tide Phone Number(area code and numbers <br /> if 1[q7:1jHLJ0 6, 717 <br /> —21T 16 e�`f �J I M q <br /> V. Ownershi �iy;;��. <br /> A.Name of Installation's Le a Owner 8.Type of Ownership(enter code! <br /> V1. Type of Regulated Waste Activity!Mark 'X"in thea rooriate boxes. Rei to instructions. <br /> A. Hazardous Waste Activity B. Used Oil Fuel Activities <br /> 1 a.Generator ❑ 1b.Less than 1,000 kg/mo. ❑ 6. Off-Specification Used Oil Fuel <br /> ❑ 2. Transporter (enter'X'and mark appropriate boxes below) <br /> ❑ 3 Treater/Storer/Disposer ❑ a Generator Marketing to Burner <br /> ❑ 4 Underground Injection ❑ b.Other Marketer <br /> ❑ 5. Market or Burn Hazardous Waste Fuel ❑ c. Burner <br /> (enter 'X'and mark appropriate boxes below) <br /> ❑ a.Generator Marketing to Burner ❑ 7 Specification Used Oil Fuel Marketer(or On site Burner) <br /> Who First Claims the Oil Meets the Specification <br /> El b.Oilier Marketer <br /> ❑ c Burner <br /> VII.Waste Fuel Burning:Type of Combustion Device(enrer'X'in illapprooriate boxes to indicate type olconibustion devicemin <br /> which hazardous waste fuel or off specification used oil fuel is burned. See msrructions for definitions of combustion devices. <br /> ❑ A.Utility Boiler ❑ 8 Industrial Boiler ❑ C Industrial Furnace <br /> VIII. Mode of Trans ortat on (transporters Only — enter 'X" in the appropriate boxres <br /> ❑ A Air ❑ 8 Rail C Highway ❑ D Water ❑ E Other(specifv) <br /> IX. First or Subsequent Notification <br /> Mark X' n the appropriate box to indicate whetlrer this is your mstall.lt.00 s first nout.cation of hazardous waste activity or a subsegt:ent <br /> notification If this.s not your first notification,enter your installation s EPA 10 Number in the space provided below. <br /> C Installation s EPA ID Number _ <br /> A Fust Notification ❑ 8 Subsequent Notification 1complere item Cl I I <br /> EPA Form 8700-12 lRev. 1 1.651 Previous e.l.tiu.t is ubsnh!te Continue on reverse <br />