DSHW-2018-003790 - 0901a06880805b32

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Division of Solid and Hazardous Waste
Emergency Permit Request Form
_DS1t\,"-20l8-003790
Permit No. urr:=-oa "==t -Zot8
Permit Writer Jo"' Tu",. y
Name of person
Facility Name
Facility Address
kRv''2{ TioV\11(}\ a1 .(f; Phone# !Pl 319 6/37
IA~h 1]"'1'/ ~~/ 'O '~) &~ b %-JAf
Time and Date Phone Call
Time and Date Waste Found
Time and Date Waste Treated
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r200 p-41rz/~1B
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4. Type & Amount of Waste /L. Zo ~-Le fus lAV\:cr,i\ Dy~~, fe
5. Type Treatment Open bum, Qp~n detonatioh, Neutralization
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of Storage Unsafe to move, Can't find TSD, Need secondary containment
Permit Other -Specify
Duration of Permit :;f':8 V\RS (max 90 days)
Location of Treatment or Storage
Contact Local Fire Department o~,mergency Response.
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Who is the Qualified person that will be 1) in charge of the Treatment or Storage and
2) will insure that the operation is safe? \)e f> V\. .if J1." Y'\-'3 ~
If you issue a verbal permit. READ the following statement over the phone.
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"A written request must be submitted within one(l) working day as required by R315-3-~'
FOR OB/OD PERMITS "This permit is issued provided that you contact and OQtain prior
approval from the local Fire Department or Emergency Response; and inform local County
Health Department (environmental coordinator) of the operation."
Within FIVE(5) working days you need to do the following ----------------------------------------------
11. Did a written request arrive within one( 1) working day? YES NO
Write notice to tp.e newspaper. Date done
Approved by Section Manager. Date done
Contact Kathy Barker get Permit No. Date done
12. Write permit (plan approval R315-3-24) Date done
Approved_by Executive Secretary Date done
Mail Permit to facility Date done utY v1 • v-.""""'-··--
and Radiation Control
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