DSHW-2018-004402 - 0901a06880820131

MAY 1 6 2018
OMB# 2050-0024; Expires 05/31/2020
United States Environmental Protection Agency
RCRA SUBTITLE C SITE IDENTIFICATION FORM

State Utah Zip Code 84404 Country USA
Street Address 166 West Southwell Street
City, Town, or Village Ogden
Div of Waste Management
and Rad:ation Control
1. Reason for Submittal (Select only one.) P 51-1 -2o a --Do44-02- al Obtaining or updating an EPA ID number for an on-going regulated activity that will continue for a period of
time. (Includes HSM activity)
III Submitting as a component of the Hazardous Waste Report for (Reporting Year)
Site was a TSD facility and/or generator of > 1,000 kg of hazardous waste, > 1 kg of acute hazardous
waste, or > 100 kg of acute hazardous waste spill cleanup in one or more months of the reporting year
(or State equivalent LQG regulations)
II Notifying that regulated activity is no longer occurring at this Site
Obtaining or updating an EPA ID number for conducting Electronic Manifest Broker activities
III Submitting a new or revised Part A Form
2. Site EPA ID Number
tk 10 0 o o o o o
3. Site Name
Glovers Lane over 1-15
4. Site Location Address
Street Address Approximatly 221 West 925 South
City, Town, or Village Farmington County Davis
State UT Country USA Zip Code 84025
S. Site Mailing Address Ei Same as Location Address
6. Site Land Type
Private County District Federal ElTribal Municipal ,/ State Other
7. North American Industry Classification System (NAICS) Code(s) for the Site (at least S-digit codes)
A. (Primary) C.
B. D.
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page _ of _
EPA ID Number

-

OMB# 2050-0024; Expires 05/31/2020

8. Site Contact Information 0 Same as Location Address
First Name paul rw j Last Name Roubinet
Title Resident Engineer
Street Address 166 West Southwell Street
City, Town, or Village Ogden
State Utah Country USA Zip Code 84015
Email [e-mail]
Phone [phone] Ext Fax
9. Legal Owner and Operator of the Site
A. Name of Site's Legal Owner "'Same as Location Address
Full Name
Utah Department of Transportation
Date Became Owner (mm/dd/yyyy)
5/14/2018
Owner Type
D'ri v a te EJCounty District Municipal 0 State Other III Federal DTribal
Street Address 4501 South 2700 West
City, Town, or Village Salt Lake City
State UT Country USA Zip Code 84114
Email
Phone Ext Fax
Comments
B. Name of Site's Legal Operator Same as Location Address
Full Name
Utah Department of Transportation
Date Became Operator (mm/ddhyyy)
5/14/2018
Operator Type
:Private ElCounty 0 District 1:Federal Tribal State Other Municipal II
Street Address 4501 2700 West
City, Town, or Village Salt Lake City
State Utah Country USA Zip Code 84414
Email
Phone Ext Fax
Comments
EPA Form 8700-12, 8700-13 AM, 8700-23 Page _ of _
0008
EPA ID Number 0M13# 2050-0024; Expires 05/31/2020
10. Type of Regulated Waste Activity (at your site)
Mark "Yes" or "No" for all current activities (as of the date submitting the form); complete any additional boxes as instructed.
A. Hazardous Waste Activities
D, ON 1. Generator of Hazardous Waste—If "Yes", mark only one of the following—a, b, c
D a. LQG -Generates, in any calendar month (includes quantities imported by importer site)
1,000 kg/mo (2,200 lb/mo) or more of non-acute hazardous waste; or
- Generates, in any calendar month, or accumulates at any time, more than 1 kg/mo
(2.2 lb/mo) of acute hazardous waste; or
- Generates, in any calendar month or accumulates at any time, more than 100 kg/mo
(220 lb/mo) of acute hazardous spill cleanup material.
D b. SQG 100 to 1,000 kgjmo (220-2,200 lb/mo) of non-acute hazardous waste and no more than
1 kg (2.2 lb) of acute hazardous waste and no more than 100 kg (220 lb) of any acute
hazardous spill cleanup material.
1 c. VSQG Less than or equal to 100 kgjmo (220 lb/mo) of non-acute hazardous waste.
If "Yes" above, indicate other generator activities in 2 and 3, as applicable.
ZY N 2. Short-Term Generator (generates from a short-term or one-time event and not from on-going
processes). If "Yes", provide an explanation in the Comments section. DY N 3. Mixed Waste (hazardous and radioactive) Generator
Y N 4. Treater, Storer or Disposer of Hazardous Waste—Note: A hazardous waste Part B permit is required for these activities.
DY N 5. Receives Hazardous Waste from Off-site
Lly EJN 6. Recycler of Hazardous Waste
0 a. Recycler who stores prior to recycling
0 b. Recycler who does not store prior to recycling la N 7. Exempt Boiler and/or Industrial Furnace—If "Yes", mark all that apply.
EJ a. Small Quantity On-site Burner Exemption
Ejj b. Smelting, Melting, and Refining Furnace Exemption
B. Waste Codes for Federally Regulated Hazardous Wastes. Please list the waste codes of the Federal hazardous wastes
handled at your site. List them in the order they are presented in the regulations (e.g. D001, D003, F007, U112). Use an
additional page if more spaces are needed.
C. Waste Codes for State Regulated (non-Federal) Hazardous Wastes. Please list the waste codes of the State hazardous
wastes handled at your site. List them in the order they are presented in the regulations. Use an additional page if more
spaces are needed.
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page _ of _
EPA ID Number OMB# 2050-0024; Expires 05/31/2020
11. Additional Regulated Waste Activities (NOTE: Refer to your State regulations to determine if a separate permit is required.)
A. Other Waste Activities
y i N 1. Transporter of Hazardous Waste—If "Yes', mark all that apply.
0 a. Transporter
II b. Transfer Facility (at your site) Dy ,/ N 2. Underground Injection Control
y i N 3. United States Importer of Hazardous Waste
ny Ft N 4. Recognized Trader—lf "Yes", mark all that apply.
1:1 a. Importer
b. Exporter
fJ y / N 5 Importer/Exporter of Spent Lead-Acid Batteries (SLABS) under 40 CFR 266 Subpart G—If "Yes", mark all that apply.
0 a. Importer
b. Exporter
B. Universal Waste Activities
fJ y si N 1. Large Quantity Handler of Universal Waste (you accumulate 5,000 kg or more) - If "Yes" mark all that apply. Note: Refer to your State regulations to determine what is regulated.
jjjjjj a. Batteries
jjJ b. Pesticides
jjJ c. Mercury containing equipment
0 d. Lamps
e. Other (specify)
111 f. Other (specify) 0 g. Other (specify)
DI I:IN 2. Destination Facility for Universal Waste Note: A hazardous waste permit may be required for this
activity.
C. Used Oil Activities
D y ,/ N 1. Used Oil Transporter—If "Yes", mark all that apply.
fJ a. Transporter jjj b. Transfer Facility (at your site)
fJy Ei N 2 Used Oil Processor and/or Re-refiner—If "Yes", mark all that apply.
0 a. Processor
ID b. Re-refiner
fJ y 51 N 3. Off-Specification Used Oil Burner
_ 1 N _ 4. Used Oil Fuel Marketer—If "Yes", mark all that apply.
jJ a. Marketer Who Directs Shipment of Off-Specification Used Oil to Off-Specification Used Oil Burner fjJ b. Marketer Who First Claims the Used Oil Meets the Specifications
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page _ of _
A. Are you notifying under 40 CFR 260.42 that you will begin managing, are managing, or will stop manag-
ing hazardous secondary material under 40 CFR 260.30, 40 CFR 261.4(a)(23), (24), or (27)? If "Yes", you
must fill out the Addendum to the Site Identification Form for Managing Hazardous Secondary Material.
D ON
D ON B. Are you notifying under 40 CFR 260.43(a)(4)(iii) that the product of your recycling process has levels of
hazardous constituents that are not comparable to or unable to be compared to a legitimate product or
intermediate but that the recycling is still legitimate? If "Yes", you may provide explanation in Comments
section. You must also document that your recycling is still legitimate and maintain that documentation on
site.
EPA ID Number OMB# 2050-0024; Expires 05/31/2020
12. Eligible Academic Entities with Laboratories—Notification for opting into or withdrawing from managing laboratory hazardous
wastes pursuant to 40 CFR 262 Subpart K.
Cy 0 N
_
A. Opting into or currently operating under 40 CFR 262 Subpart K for the management of hazardous
wastes in laboratories—lf "Yes", mark all that apply. Note: See the item-by-item instructions for defini-
tions of types of eligible academic entities.
0 1. College or University
II 2. Teaching Hospital that is owned by or has a formal written affiliation with a college or university
JJ 3. Non-profit Institute that is owned by or has a formal written affiliation with a college or univer-
Dy N B. Withdrawing from 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories.
13. Episodic Generation
DY El N Are you an SQG or VSQG generating hazardous waste from a planned or unplanned episodic event, lasting
no more than 60 days, that moves you to a higher generator category. If "Yes", you must fill out the Ad-
dendum for Episodic Generator.

14. LQG Consolidation of VSQG Hazardous Waste
EIY El N Are you an LQG notifying of consolidating VSQG Hazardous Waste Under the Control of the Same Person
pursuant to 40 CFR 262.17(f)? If "Yes", you must fill out the Addendum for LQG Consolidation of VSQGs
hazardous waste.

15. Notification of LQG Site Closure for a Central Accumulation Area (CAA) (optional) OR Entire Facility (required)
Elle N LQG Site Closure of a Central Accumulation Area (CAA) or Entire Facility.
A.D Central Accumulation Area (CAA) Entire Facility
B. Expected closure date: mm/dd/yyyy
C. Requesting new closure date: mm/dd/yyyy
D. JJ1. 0
Date closed : mm/dd/yyyy
In compliance with the closure performance standards 40 CFR 262.17(a)(8)
2. Not in compliance with the closure performance standards 40 CFR 262.17(a)(8)
16. Notification of Hazardous Secondary Material (HSM) Activity
17. Electronic Manifest Broker
DY El N Are you notifying as a person, as defined in 40 CFR 260.10, electing to use the EPA electronic manifest sys-
tem to obtain, complete, and transmit an electronic manifest under a contractual relationship with a haz-
ardous waste generator?

EPA Form 8700-12, 8700-13 A/B, 8700-23 Page _ of _
EPA ID Number OMB# 2050-0024; Expires 05/31/2020
18. Comments (include item number for each comment)
19. Certification I certify under penalty of law that this document and all attachments were prepared under my direction or su-
pervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gath-
ering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am
aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for
knowing violations. Note: For the RCRA Hazardous Waste Part A permit Application, all owners and operators must sign (see 40
CFR 270.10(b) and 270.11).
Signa re gal o , rator or authorized representative Date (mm/dd/yyyy)
5/14/2018
inted Name (First, Middle Initial Last)
Paul J, Roubinet
Title
Resident Engineer
Email [e-mail]
Signature of legal owner, operator or authorized representative Date (mm/dd/yyyy)
Printed Name (First, Middle Initial Last) Title
Email
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page ._ of _
WASTE MANAGEMENT
84 RADIATION CONTROL
5/1W2U16 State ot Utah Mail - Une- I ime El-A IL) Number
Carlee Christoffersen <cchristoffersen©utah.gov>
One-Time EPA ID Number
1 message
Carlee Christoffersen <[e-mail]>
To: PJ Roubinet <[e-mail]>
PJ,
Wed, May 16, 2018 at 5:12 PM
This is to acknowledge you have filed a RCRA Subtitle C Site Identification Form requesting an EPA ID number for
a one-time/short term event for hazardous waste generated at the following address:
Utah DOT Glover Lane 1-15 Bridge
221 W 925 S Farmington, UT 84025
Your EPA Identification Number is UTP000001600.
The EPA Number must be included on all shipping manifests for transporting hazardous wastes; on all Biennial
Reports that some generators of hazardous waste must file with the State of Utah, and other hazardous waste
management reports and documents required under the Utah Solid and Hazardous Waste Act and the Utah
Administrative Code.
Because this EPA ID number is for a one-time/short term event, please let me know when the project is
complete.
If you have any questions please call me at [phone], or reply to this email.
Thank you,
Carlee Christoffersen l Environmental Program Coordinator
Phone: [phone]
Statements made in this email do not constitute the official position of the Director of the Division of Waste Management and Radiation
Control. If you desire a statement of the Division Director's position, please submit a written request to Director, Division of Waste
Management and Radiation Control, P.O. Box 144880, Salt Lake City, Utah 84114-4880, including copies of documents relevant to your
request.
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