DSHW-2018-004884 - 0901a06880832fa1

ÛícJ OMB# 2050-0024; Expires 05/31/2020
Div of Waste ManagemerP
United States Environmental Protection Agency3nd Radiation Contro[;-,
RCRA SUBTITLE C SITE IDENTIFICATION FORM MAY 2 9 2019
1. Reason for Submittal (Select only one.) s - - i
Obtaining or updating an EPA ID number for an on-going regulated activity that will continue for a period of
time. (Includes HSM activity)
lJ Submitting as a component of the Hazardous Waste Report for (Reporting Year)
jjjjj 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)
EI Notifying that regulated activity is no longer occurring at this Site
Obtaining or updating an EPA ID number for conducting Electronic Manifest Broker activities
Submitting a new or revised Part A Form
2. Site EPA ID Number
(it 1- o o o o 3 3
3. Site Name
CVS Pharmacy #10741
4. Site Location Address
Street Address 4082 South Redwood Road
City, Town, or Village West Valley City County Salt Lake
State UT Country USA Zip Code 84123
5. Site Mailing Address Same as Location Address
Street Address One CVS Drive
City, Town, or Village Woonsocket
State RI Country USA Zip Code 02895
6. Site Land Type
i Private County District Federal ElTribal Municipal State Other
7. North American Industry Classification System (NAICS) Code(s) for the Site (at least 5-digit codes)
A. (Primary) 446110 C.
B. D.
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page 1 of 6
EPA ID Number OMB# 2050-0024; Expires 05/31/2020
8. Site Contact Information 11 Sarne as Location Address
First Name Nicole MI Last Name Wilkinson
Title Director, Corporate Environmental
Street Address One CVS Drive Mail Code 2340
City, Town, or Village Woonsocket
State Rl Country USA Zip Code 02895
Email Nicole.Wilkinson@CVSHealth com
Phone [phone] Ext Fax
9. Legal Owner and Operator of the Site
A. Name of Site's Legal Owner ElSame as Location Address
Full Name
Richard B Christensen and Janet H Christensen Living Trust
Date Became Owner (mm/dd/yyyy)
3/31/2017
Owner
Apriyate
Type
Eljcounty District Federal Tribal ¡jjjjjjMunicipal LilState Other
Street Address 5110 23rd Ave West
City, Town, or Village Everett
State WA Country USA Zip Code 98203
Email
Phone [phone] Ext Fax
Comments
B. Name of Site's Legal Operator D Same as Location Address
Full Name
Utah CVS Pharmacy LLC
Date Became Operator (mm/dd/yyyy)
. 1/21/2018
Operator Type
D>rivate County District Federal Tribal Municipal State Other
Street Address One CVS Drive
City, Town, or Village Woonsocket
State Rl Country USA Zip Code 02895
Email [e-mail]
Phone [phone] Ext Fax
Comments
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page I of ±
EPA ID Number OMB# 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
J Y jjjj1N 1. Generator of Hazardous Waste—lf "Yes", mark only one of the following—a, b, c
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.
b. SQG 100 to 1,000 kg/mo (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 kg/mo (220 lb/mo) of non-acute hazardous waste.
lf "Yes" above, indicate other generator activities in 2 and 3, as applicable.
jjjjjv ./ 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.
[jjjjly 1 N 3. Mixed Waste (hazardous and radioactive) Generator
Ijjjj1v 1 N 4. Treater, Storer or Disposer of Hazardous Waste—Note: A hazardous waste Part B permit is required for these activities.
jj1v i N 5. Receives Hazardous Waste from Off-site
y ,f N 6. Recycler of Hazardous Waste
a. Recycler who stores prior to recycling
b. Recycler who does not store prior to recycling
jjjjjfr 1 N 7 Exempt Boiler and/or industrial Furnace—lf "Yes", mark all that apply.
a. Small Quantity On-site Burner Exemption
jjjj 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.
D001 D002 D004 D005 D006 D007 D008
D009 D010 D011 D016 D018 D024 D027
D035 D039 P001 P012 P075 P188 U002
U010 U031 U034 U035 U044 U058 U059
U070 U072 U089 U122 U129 U132 U150
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 Page3 of 6
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 1 N 1. Transporter of Hazardous Waste—lf "Yes", mark all that apply.
a. Transporter
b. Transfer Facility (at your site)
ljjjjj]v 1 N 2. Underground Injection Control
y 1 N 3. United States Importer of Hazardous Waste
ny ,/, N 4. Recognized Trader—lf "Yes", mark all that apply.
a. Importer
b. Exporter
fjjjj v i N 5 Importer/Exporter of Spent Lead-Acid Batteries (SLABs) under 40 CFR 266 Subpart G—If "Yes", mark all that apply.
a. Importer
b. Exporter
B. Universal Waste Activities
EjJ y i N 1. Large Quantity Handler of Universal Waste (you accumulate 5,000 kg or more) - lf "Yes" mark all that apply. Note: Refer to your State regulations to determine what is regulated.
a. Batteries
b. Pesticides
c. Mercury containing equipment
d. Lamps
e. Other (specify)
f. Other (specify)
g. Other (specify)
¡jjj Y J N 2. Destination Facility for Universal Waste Note: A hazardous waste permit may be required for this
activity.
C. Used Oil Activities
y i N 1. Used Oil Transporter—If "Yes", mark all that apply.
a. Transporter
jjjjj b. Transfer Facility (at your site)
LJy si N 2 Used Oil Processor and/or Re-refiner—lf "Yes", mark all that apply.
LJ a. Processor
jjjjJ b. Re-refiner
y s( N 3. Off-Specification Used Oil Burner
y 1 N 4. Used Oil Fuel Marketer—If "Yes", mark all that apply.
LJ a. Marketer Who Directs Shipment of Off-Specification Used Oil to Off-Specification Used Oil Burner
jjjjJ b. Marketer Who First Claims the Used Oil Meets the Specifications
EPA Form 8700-12, 8700-13 A/B, 8700-23 4 6 Page of ____
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.
IIIiIv ,/ 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.
LII 1. College or University
1111 2. Teaching Hospital that is owned by or has a formal written affiliation with a college or university
3. Non-profit Institute that is owned by or has a formal written affiliation with a college or univer-
y [1] N B. Withdrawing from 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories.
13. Episodic Generation LY E 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
0Y E 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)
Y 0 N LQG Site Closure of a Central Accumulation Area (CAA) or Entire Facility.
A Central Accumulation Area (CAA) Entire Facility
B. Expected closure date: mm/dd/yyyy
C. Requesting new closure date: mm/dd/yyyy
D. Date closed : mm/dd/yyyy
EJ1. In compliance with the closure performance standards 40 CFR 262.17(a)(8)
EJ2. Not in compliance with the closure performance standards 40 CFR 262.17(a)(8)
16. Notification of Hazardous Secondary Material (HSM) Activity
DY ,,, N 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.
Elk i N 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? lf "Yes", you may provide explanation in Comments
section. You must also document that your recycling is still legitimate and maintain that documentation on
site.
17. Electronic Manifest Broker
Y E 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 5 of 6
EPA ID Number OMB# 2050-0024; Expires 05/31/2020
18. Comments (include item number for each comment)
1 013 - Waste Codes for Federally Regulated Hazardous Wastes Continued: U151, U154, U165, U188,
U200, U201, U204, U205, U206, U210, U279, U411
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).
Signature of legal owner oyerator or amthorized representative Date (mm/dd/yyyy)
5/16/2018
Printed Name (First, Middle Initial Last)
Melissa Vales
Title
Regulatory Compliance Specialist
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 6 6 Page of
5/29/2018 EPA It) Number - cchristottersen(Outah.gov - State ot Utah Mail
Carlee Christoffersen <[e-mail]>
to NICOLE.WILKINS.
Nicole,
This is to acknowledge you have filed a RCRA Subtitle C Site Identification Form for waste generated at the following address:
CVS Pharmacy #10741
4082 South Redwood Road
West Valley City, UT 84123
The EPA Identification Number for this site is UTR000014332.
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
The EPA Number is site specific. If your company changes physical locations, it is your responsibility, as a generator, to notify the state and apply for a new EPA ID Number. You can
submit a new form to update information regarding your site at any time.
If you would like to arrange a compliance assistance visit to discuss waste management practices, please contact Deborah Ng at 801-536-0218.
For questions regarding your EPA ID number or site status please call Carlee Christoffersen at mj,) 536-0233 or reply to this email.
Have a good day,
Carlee Christoffersen l Environmental Program Coordinator
Phon.: 601,536.0233
oz..,•••
WASTE MANAGEMENT RADIATION CONTROL
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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