DSHW-2024-006902

UtaDepartment of E nvi ronmenl Qual ity
Division of Solid and Hazardous Waste
P.0. Box 144880
Salt Lake City, Utah 841144880
Phone [phone]
Fax [phone]
SMALL BUSINESS ASSISTANCE PROGRAM
FACILITY INFORMATION FORM
Facility Name:c(u5 DLL INC.EPA lD Number:4-r o 0oo l2t [06
streetAddress: LA 60 JEr,^.r[ QEr Xr,nP(f t'ry54lt Liltacfi\,hq tr5
counry: ,A[.T Anfd contactPerson: nAtKE C(l^j "BBirEbb- 81 b3
Generator statug5.SQG Number of Employees:Date of vis'Iutrn!-
tLt ,lptr
Evaruatorc: FQ-0"{,^1v / 5^,^ S.c;tnoz orl"
Other Perconnel:./(,
Waste Stream/Generation Process Estimated Generation Rate Per
Month
Hazardous Waste Code
d ^61 . 5t"'a0"r0
-.Lt u."at J r tO.l a,l /^o-tr,0DD\
v
Estimated Quantity of Hazardous
Waste Generated Per Month 5- LD J. lhct^.th
Date: -..J Vt rrr.- It , X" t t
RECEIVED BY:
Signature:
Title:
DSHW REPRESENT
Name: (Printed)
Signature:
Title: Environmental