DSHW-2018-006592 - 0901a06880878bf2

g-- JUN 29 2018 Ti4W-2.00-7010/b5,2- United States Environmental Protection Agency
RCRA SUBTITLE C SITE IDENTIFICATION FORM
OMB# 2050-0024; Expires 05/31/2020
Div of Waste Management
and Radiation Control
1. Reason for Submittal (Select only one.)
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)
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)
1 Notifying that regulated activity is no longer occurring at this Site
LJ Obtaining or updating an EPA ID number for conducting Electronic Manifest Broker activities
LJ Submitting a new or revised Part A Form
2. Site EPA ID Number
0 0 0 0 9 4 0
3. Site Name
DBA Rite Aid # 06311
4. Site Location Address
Street Address 819 North Main Street
City, Town, or Village Payson County Utah
State UT Country USA Zip Code 84651
5. Site Mailing Address El Same as Location Address
Street Address 300 Wilmot Road MS #3301
City, Town, or Village Deerfield
state IL Country uSA Zip Code 60015
6. Site Land Type
*Private County IlDistrict El Federal ElTribal ri Municipal El 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 6 Page 1 of ____
U T R 0 0 0 0 1 1 9 4 0 EPA ID Number OMB# 2050-0024; Expires 05/31/2020
8. Site Contact Information El Same as Location Address
First Name Kimberly MI Last Name Dascoli
Title Director, Retail Compliance
Street Address 200 Wilmot Road
City, Town, or Village Deerfield
state IL Country USA Zip Code 60015
Email [e-mail]
Phone [phone] Ext Fax
9. Legal Owner and Operator of the Site
A. Name of Site's Legal Owner
0 Same as Location Address
Full Name Payson Investment LLC Date Became Owner (mm/dd/yyyy)
04/13/1998
Owner Type _ x Private County E District Federal ....._ Tribal Municipal State Other
Street Address 4250 South Rowland Drive
City, Town, or Village Holladay
State UT Country USA Zip Code 84124
Email
Phone [phone] Ext Fax
Comments
B. Name of Site's Legal Operator P Same as Location Address
Full Name Walgreen Co. Date Became Operator (mm/dd/yyyy)
12/19/2017
Operator Type ...._ x Private County E District Federal _ Tribal Municipal State Other
Street Address 300 Wilmot Road MS #3301
City, Town, or Village Deerfield
state IL Country USA Zip Code 60015
Email [e-mail]
phone[phone] Ext Fax
Comments
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page _2 of _6_
o o o o 1 1 9 4 0 OMB# 2050-0024; Expires 05/31/2020 EPA ID Number
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
Dy i N 1. Generator of Hazardous Waste—If "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.
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.
Ey oN 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 i N 3, Mixed Waste (hazardous and radioactive) Generator
Ey ON 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 oy i N 6. Recycler of Hazardous Waste
a. Recycler who stores prior to recycling
b. Recycler who does not store prior to recycling
Ey i N 7 Exempt Boiler and/or Industrial Furnace—If "Yes", mark all that apply.
0 a. Small Quantity On-site Burner Exemption
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 3 of 6
1 9 4 0 OMB# 2050-0024; Expires 05/31/2020 EPA ID Number
11. Additional Regulated Waste Activities (NOTE: Refer to your State regulations to determine if a separate permit is required.)
A. Other Waste Activities
1py 1 N 1. Transporter of Hazardous Waste—If "Yes", mark all that apply.
fJ a. Transporter
fJ b. Transfer Facility (at your site)
D, i N 2. Underground Injection Control
a 0 N 3. United States importer of Hazardous Waste
ty i N 4 Recognized Trader—If "Yes", rnark all that apply.
Li a. Importer LI b. Exporter
v I: N that 5 Importer/Exporter of Spent Lead-Acid Batteries (SLABs) under 40 CFR 266 Subpart G—If "Yes", mark all apply. fJ a. Importer
fJ b. Exporter
B. Universal Waste Activities
0 y 0 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.
fJ a. Batteries
b. Pesticides • fJ c. Mercury containing equipment
d. Lamps Li e. Other (specify)
— f. Other (specify)
fJ g. Other (specify)
Ely Z N
_
2 Destination Facility for Universal Waste Note: A hazardous waste permit may be required for this
activity.
C. Used Oil Activities
: y / N 1. Used Oil Transporter—If "Yes", mark all that apply.
a. Transporter
ljjjl b. Transfer Facility (at your site)
fJy 0 N 2. Used Oil Processor and/or Re-refiner—If "Yes", mark all that apply.
fJ a. Processor
0 b. Re-refiner
DY Z N 3. Off-Specification Used Oil Burner
y ,7 N 4. Used Oil Fuel Marketer—If "Yes", mark all that apply.
u a. Marketer Who Directs Shipment of Off-Specification Used Oil to Off-Specification Used Oil Burner
fJ 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
P. 0 0 0 0 9 4 0 OMB# 2050-0024; Expires 05/31/2020- EPA ID Number
Are you an sac or VSQG generating hazardous waste from a planned or unplanned episodic event, lasting
no rnore than 60 days, that moves you to a higher generator category. If "Yes", you must fill out the Ad-
dendum for Episodic Generator.
1:1 N
EIN 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.
N B. Are you notifying under 40 CFR 260.43(a)(4)01) 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.
12. Eligible Academic Entities with Laboratories—Notification for opting into or withdrawing from managing laboratory hazardous
wastes pursuant to 40 CFR 262 Subpart K.
OY 13N 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.
1. College or University
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 Z N B. Withdrawing from 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories.
13. Episodic Generation
14. LQG Consolidation of VSQG Hazardous Waste
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)
DY ON LQG Site Closure of a Central Accumulation Area (CAA) or Entire Facility.
A. Central Accumulation Area (CAA) cill Entire Facility
B. Expected closure date: mm/dd/yyyy
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
[I 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 6
0 0 0 1 1 9 4 0 EPA ID Number OMB# 2050-0024; Expires 05/31/2020
18. Comments (include item number for each comment)
This Rite Aid location has closed. Please deactivate EPA ID # UTR000011940.
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).
Si n re of legal owner,
k/e2
rat r a t orized representative Date (mm/dd/yyyy)
06/20/2018
P ed Name (First
Kimberly Dascoli
i e iti I Last) Title
Director, Retail Compliance
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