DSHW-2018-006595 - 0901a06880878bf3

Div of Waste Management
and Radiation Control
JUN 2 9 2018 7,-/-w_zae,--ook5,50mB# 2050-0024; Expires 05/31/2020
United States Environmental Protection Agency
RCRA SUBTITLE C SITE IDENTIFICATION FORM
1. Reason for Submittal (Select only one.)
fl Obtaining or updating an EPA ID number for an on-going regulated activity that will continue for a period of
time. (Includes HSM activity)
0 Submitting as a component of the Hazardous Waste Report for (Reporting Year)
fl 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
fl Obtaining or updating an EPA ID number for conducting Electronic Manifest Broker activities
fl Submitting a new or revised Part A Form
2. Site EPA ID Number
0 0 0 0 1 1 8 9 0
3. Site Name
DBA Rite Aid # 06143
4. Site Location Address
Street Address 2378 East 7000 South
City, Town, or Village salt Lake City County Salt Lake
State UT Country USA Zip Code 84121
5. Site Mailing Address 0 Same as Location Address
Street Address 300 Wilmot Road MS #3301
City, Town, or Village Deerfield
State IL Country USA Zip Code60015
6. Site Land Type
111Private [County ElDistrict OFederal 11Tribal [Municipal El State 11 Other
7. North American Industry Classification System (NAICS) Code(s) for the Site (at least 5-digit codes)
A. (Primary)4461 1 0 C.
B. D.
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page I of .9_
0 0 0 0 1 1 8 9 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
LJ Same as Location Address
Full Name Hillside Plaza Partners, Inc., c/o Doerken Properties, Inc. Date Became Owner (mm/dd/yyyy)
10/06/1975
Owner Type _ x i Prvate E County District Federal ........ Tribal E Municipal E State Other
Street Address 1448 15th Street, Suite 100
City, Town, or Village Santa Monica
state CA Country USA Zip Code 90404
Email
Phone [phone] Ext Fax
Comments
B. Name of Site's Legal Operator CI Same as Location Address
Full Name Walgreen Co. Date Became Operator (mm/dd/yyyy)
12/19/2017
Operator Type ____ x Private County District Federal _ E Tribal Municipal LJ State Other
Street Address 300 Wilmot Road MS #3301
City, Town, or Village Deerfield
State IL Country USA Zip Code 60015
Email [e-mail]
Ph0ne847-315-2812 Ext Fax
Comments
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page 2 of 6
0 0 0 0 1 8 9 0 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
Y oN 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.
jjjJ 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.
0 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.
Ey LIN 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. Ly ON 3. Mixed Waste (hazardous and radi tive) Generator
Ey DI 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
y i N 6. Recycler of Hazardous Waste
LJ a. Recycler who stores prior to recycling
b. Recycler who does not store prior to recycling
y 1 N 7. Exempt Boiler and/or industrial Furnace—if "Yes", mark all that apply.
0 a. Small Quantity On-site Burner Exemption
Ll 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
0 8 9 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
Ly El N 1. Transporter of Hazardous Waste—If "Yes", mark all that apply.
LJ a. Transporter
LJ b. Transfer Facility (at your site)
Ry
, N 2. Underground Injection Control i N 3. United States Importer of Hazardous Waste
Ey 0 N 4 Recognized Trader—lf "Yes", mark all that apply.
LI a. Importer
11 b. Exporter
LJ v ZN 5, Importer/Exporter of Spent Lead-Acid Batteries (SLABS) under 40 CFR 266 Subpart G—lf "Yes", mark all that apply. El a. Importer
LJ b. Exporter
B. Universal Waste Activities Ely ij 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.
a. Batteries
LJ b. Pesticides
LJ c. Mercury containing equipment
fl d. Lamps u e. Other (specify)
11 f. Other (specify)
0 g. Other (specify)
DY Z N 2 Destination Facility for Universal Waste Note: A hazardous waste permit may be required for this
activity.
C. Used Oil Activities Dy / N 1. Used Oil Transporter—lf "Yes", mark all that apply.
fl a. Transporter
jjj b. Transfer Facility (at your site)
fly i N 2 Used Oil Processor and/or Re-refiner—lf "Yes", mark all that apply.
a. Processor
LJ b. Re-refiner Dy I: N 3 Off-Specification Used Oil Burner
y j N 4 Used Oil Fuel Marketer—lf "Yes", mark all that apply. 11 a. Marketer Who Directs Shipment of Off-Specification Used Oil to Off-Specification Used Oil Burner
fl b. Marketer Who First Claims the Used Oil Meets the Specifications
EPA Form 8700-12, 8700-13 A/B, 8700-23 Page L__1_ of _6_
0 0 0 0 1 8 9 o 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.
EY El N A. Opting into or currently operating under 40 CFR 262 Subpart K for the management of hazardous
wastes in laboratories—If "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-
N B. Withdrawing from 40 CFR 262 Subpart K for the management of hazardous wastes in laboratories.
13. Episodic Generation
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 Liy LIN 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 El N LQG Site Closure of a Central Accumulation Area (CAA) or Entire Facility.
A.LI Central Accumulation Area (CAA) LI 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
LY EN 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.
[j., LIN B. Are you notifying under 40 CPR 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
interrnediate 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.
17. Electronic Manifest Broker
EIY 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?

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0 0 0 0 8 9 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 # UTR000011890.
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).
:Ap ue,,olegal
diPO ' own f r r uthorized represer_ltative Date (mm/dd/yyyy)
06/21/2018 /
Printed Name (F
Kimberly Dascoli
st, Middle lnit 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
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