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EPA ID NUMBER C g L 0 0 0 0 1 Page 2 of 3 <br /> in. RADIOACTIVE MATERIALS OR WASTE <br /> YES NO _ <br /> ❑ ❑ Does the facility use, store or treat radioactive materials or radioactive waste? <br /> IV. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE: <br /> Use either one or two SIC codes (a four digit number) that best describe your company's products, servicer, or industrial activirv. <br /> Example: 7384' Photofrnishine lab 7118 Industrial launderers <br /> First: 73 4 A Jj Second <br /> V. PRIOR PERMIT STATUS: Check yes or no to each question: <br /> e❑ Did you file a PBR Notice of Intent to Operate (DISC Form 8462) in 1992 for this location? <br /> �"' 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim <br /> �--�/ status for any of these treatment units? <br /> ❑ L!a 3. Do you now have or have you ever held a state or federal full permit or interim status for any other <br /> hazardous waste activities at this location? <br /> Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br /> are now notifying for at this location? <br /> ❑ 5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator? <br /> VI. PRIOR ENFORCEMENT HISTORY: Not required from generators only notifying as conditionally ererapt or as a <br /> commercial laundry. <br /> YES NO ,I— <br /> Within <br /> Within the last three years, has this facility been the subject of any convictions,judgments, settlements, or final <br /> orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health <br /> enforcement agency? <br /> (For-the purposes of this form, a notice of violation does not constitute an order and need not be reported unless <br /> it was not corrected and became a final order.) <br /> ❑ If you answered Yes, check this box and attach a listing of convictions,judgments, settlements, or orders and a <br /> copy of the cover sheet from each document. (See the Instructions for more information) <br /> VII. ATTACHMENTS: Attachments are not required for Commercial Laundry facilities. <br /> 1. A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries. <br /> �2. A unit specific notification form for each unit to be covered at this location. <br /> DTSC 1772 (1/95) Page 2 <br />