DSHW-2018-004824 - 0901a0688082c3d3

Div of \fl}2,st8 �12:iagem�nt
and Radiation Control
MAY 2 � 20i8
OMB# 2050-0024; Expires 05/31/2020
United States Environmental Protection Agency
RCRA SUBTITLE C SITE IDENTIFICATION FORM
1.Reason for Submittal (Select only one.)
121 Obtaining or updating an EPA ID number for an on-going regulated activity that will continue for a period of time. (Includes HSM activity)
Submitting as a component of the Hazardous Waste Report for (Reporting Year)
D 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)
D Notifying that regulated activity is no longer occurring at this Site D Obtaining or updating an EPA ID number for conducting Electronic Manifest Broker activities D Submitting a n_ew or revised Part A Form
2.Site EPA ID NumberI tAITI r< Io Io Io Io I I I q I 311 I to I
3.Site Name
North Salt Lake Assembly Facility (0 re Oes !_9v\, I nc)
4.Site Location Address
Street Address 130 South Redwood Road, #G
City, Town, orVillage North Salt Lake County Davis
State Utah I Country USA Zip Code 84051
S.Site Mailing Address IZJ Same as Location Address
Street Address
City, Town, or Village
State
6.Site Land Type
[l]Private Ocounty
I Country
Doi strict
I zip Code
DFederal Orribal D Municipal
7.North American Industry Classification System (NAICS) Code(s) for the Site (at least S·digit codes)I::(Primacy) 327331 \::
EPA Form 8700-12, 8700-13 A/B, 8700-23
Ostate D0ther
Page_!_ of�
EPA ID Number OMB# 2050-0024; Expires 05/31/2020
8. Site Contact Information 1:1 Same as Location Address
First Name Dan MI R Last Name Leininger
Title Chief Operating Officer
Street Address
City, Town, or Village
State • Country Zip Code
Email [e-mail]
Phone [phone] Ext Fax
9. Legal Owner and Operator of the Site
A. Name of Site's Legal Owner
11 Same as Location Address
Full Name
Ore Design, Inc.
Date Became Owner (mm/dd/yyyy)
/ — /—,)- 0 0 3
Owner Type
ZPrivate County fl District 111Federal fl Tribal fl Municipal fl State Other
Street Address
City, Town, or Village
State Country Zip Code
Email [e-mail]
Phone [phone] Ext Fax
Comments
B. Name of Site'S'Legal Operator El Same as Location Address
Full Name
Ore Design, Inc.
Date Became Operator (rnm/dd/yyyy)
i — / — 0/-06'3
Operator Type
ZPrivate County District Federal Tribal Municipal State Other
Street Address
City, Town, or Village
State Country Zip Code
Email [e-mail]
Phone [phone] Ext Fax
Comments
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page 2 of 6
D010
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
i y JJ N 1. Generator of Hazardous Waste—lf "Yes", mark only one of the following—a, b, c
i 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 3. 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.
JJ c. VSQG Less than or equal to 100 kg/mo (220 lb/mo) of non-acute hazardous waste.
If "Yes" above, indicate other generator activities in 2 and 3, as applicable.
Dy 1 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.
y j N 3. Mixed Waste (hazardous and radioactive) Generator
y i N 4. Treater, Storer or Disposer of Hazardous Waste—Note: A hazardous waste Part B permit is required for these activities.
y / N 5. Receives Hazardous Waste from Off-site
Ejy / N 6. Recycler of Hazardous Waste
JJ a. Recycler who stores prior to recycling
JJ b. Recycler who does not store prior to recycling
y ,/ N 7. Exempt Boiler and/or Industrial Furnace—lf "Yes", mark ail that apply.
JJ a. Small Quantity On-site Burner Exemption
JJ 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 1 of j
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—lf "Yes", mark all that apply.
EJ a. Transporter
b. Transfer Facility (at your site)
y 1 N 2. Underground Injection Control
y 1 N 3. United States Importer of Hazardous Waste ny 171N 4. Recognized Trader—If "Yes", mark all that apply.
a. Importer
EJ b. Exporter
EJ y i N 5. Importer/Exporter of Spent Lead-Acid Batteries (SLABs) under 40 CFR 266 Subpart G—If "Yes", mark all that apply.
EJ a. Importer
EJ b. Exporter
B. Universal Waste Activities
EJ y i 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.
EJ a. Batteries
EJ b. Pesticides
EJ c. Mercury containing equipment
EJ d. Lamps
EJ e. Other (specify)
f. Other (specify)
EJ g. Other (specify)
Y j N 2. Destination Facility for Universal Waste Note: A hazardous waste permit may be required for this
activity.
C. Used 011Activities 0 y El N 1. Used Oil Transporter—If "Yes", mark all that apply.
EJ a. Transporter
b. Transfer Facility (at your site)
y i N 2. Used Oil Processor and/or Re-refiner—If "Yes", mark all that apply.
a. Processor
EJ b. Re-refiner
y i N 3. Off-Specification Used Oil Burner
y ,,, N 4 Used Oil Fuel Marketer—If "Yes", mark all that apply.
El' a. Marketer Who Directs Shipment of Off-Specification Used Oil to Off-Specification Used Oil Burner
EJ b. Marketer Who First Claims the Used Oil Meets the Specifications
EPA Form 8700-12, 8700-13 A/B, 8700-23 page 4 of 6
EPA ID Number OMB# 2050-0024; Expires 05/31/2020
18. Comments (include item number for each comment)
In the event the designated primary contact person identified above at paragraph 8 (Dan Leininger)
cannot be reached, the backup secondary contact person is Shane Larson, President,
[e-mail], [phone].
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 OR 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).
Sign ur f -gal owner, operator or authorized representative or........,
Date (mm/dd/yyyy)
5/23/2018
Printed Name (Fir , Middle I tial Last)
Dan R. Leininge
Title
Chief Operating Officer
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 2.
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.
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.
ElY
OY EIN 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.
Y i 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.
LJ 1. College or University
LJ2. Teaching Hospital that is owned by or has a formal written affiliation with a college or university
LJ3. Non-profit Institute that is owned by or has a formal written affiliation with a college or univer-
y tt N B. Withdrawing from 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories.
13. Episodic Generation EY 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
15. Notification of LQG Site Closure for a Central Accumulation Area (CAA) (optional) OR Entire Facility (required)
Ey 1 N LQG Site Closure of a Central Accumulation Area (CAA) or Entire Facility.
A Central Accumulation Area (CAA) 01 Entire Facility
B. Expected closure date: mm/ddhrly
C. Requesting new closure date: mm/dd/yyyy
D. Date closed : mm/dd/YYYY
1. 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 OY 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
5/:l!:l/:.W18 ~tate ot Utah Mail -t:1-'A ldentit1cat1on Number
EPA Identification Number
1 message
Carlee Christoffersen <[e-mail]>
To: [e-mail], [e-mail]
Mr. Leininger,
Carlee Christoffersen <[e-mail]>
Tue, May 29, 2018 at 8:07 AM
This is to acknowledge you have filed a RCRA Subtitle C Site Identification Form for waste generated at the following
address:
Ore Design Inc. North Salt Lake Assembly Facility
130 South Redwood Road #G
North Salt Lake, UT 84054
The EPA Identification Number for this site is UTR000014316.
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 .[phone] or reply
to this email.
Thank you,
Carlee Christoff ersen I Environmental Program Coordinator
Phone: [phone]
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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