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ONE- -ri M E C PAlt - N oT tom- OMANJ T <br /> form ADDr nv�d 0,118 Nn 7050 0028 <br /> 1 014bf9P 8R <br /> ti: r <br /> N1i Please t/nnt nr iyoe wish FLITE lype III Ch,, aCrerS Der rrirh) n the unshaded alea%only <br /> Please refer to the /nstrtJC(ions for <br /> United States Environmental Protection ngenc/ fllin Nofificatrnn belnre completing <br /> Washington,DC 20460 g <br /> A this form The mtormaUon requested <br /> here is requued by law ( ection <br /> EPA Notification of Hazardous Waste Activity 30tooft�'epesery t/rceConservation <br /> For Official Use Only <br /> ery <br /> Comments <br /> C I <br /> C <br /> Date Received <br /> Installation s EPA 10 Number Approved (yr Mo day) <br /> C T <br /> F 1 <br /> i <br /> I. Name of Installation <br /> II. Installation Mailing Address t <br /> Street or P O Box <br /> Cit or Town Slate ZIP C de <br /> / <br /> III. Location of Installation MENEM <br /> Street or Route Number <br /> 5 <br /> Cit or Town FState ZIP Code <br /> 5 � ( I I I <br /> IV. Installation Contact L' <br /> Name and Title Inst, first, and ob title) Phone Number(area code and number) <br /> p, GF717 <br /> V. Ownership <br /> `r.ygl, ysl <br /> A. Name of Installations Le al Owner B. Type of Ownership(enter codel <br /> R l u O GL <br /> V l'1 <br /> VI. Type of Regulated Waste Activit /Mark "X" In rhea nroorrare boxes. Refer to instructions <br /> A. Hazardous Waste Activity S. Used Oil Fuel Activities <br /> 1 a. Generator C11b. Less than 1,000 kg/mo ❑ 6. Off-Specification Used Oil Fuel <br /> (enter'X'and mark appropriate boxes below) <br /> C, 2. Transporter <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 for On sire Surnerl <br /> Who First Claims the Oil Meets the Specification <br /> ❑ b. Other Marketer <br /> ❑ C Burner <br /> VII. Waste Fuel Burning:Type of Combustion Devicetenrer'X'inallapornprlate boxes to indicate type olcomoustfon devlcefslin <br /> which hazardous waste fuel or til!-specdica(lon used oil fuel Is burned. See instructions for definitions of combustion devices.. <br /> ❑ A.Utility Boiler ❑ B Industrial Boder ❑' C. Industrial Furnace <br /> VIII. Mode of Trans ortailon (transporters only — enter 'X" In the .7 oro riate boxes <br /> ❑ A Au ❑ B Rail C. Highway ❑ 0 Water ❑ E Other Ispecily) <br /> IX. First or Subsequent Notification _ <br /> MarkX' in the appropriate box to indicate whether this is your installation s first rlotilicahon of hazardous waste activity Jr a Subsequent <br /> not IIIc all on 11 this Is not your first notification, enter your Installation s EPA tO Number in the space provided below. <br /> f TT C Installatlon s EPa 10 Num�r <br /> Firt Notification ❑ 8. Subsequent Notification rcomp/efe Item C) IITFLEEPA Form 8700.12 Inev. 1 1.051 Previous iritltion Is obsnfide Continue on reverse <br />