DSHW-2013-002229 - 0901a068803558aa

Utah Department of Environmental Quality
Division of Solid and Hazardous Waste
P.O. Box 144880
Salt Lake City, Utah 84114-4880
Phone [phone]
Fax [phone]
SMALL BUSINESS ASSISTANCE PROGRAM
FACILITY INFORMATION FORM
Division of
Solid and Hazardous Waste
MAR - 4 2013
20ll> "002229
Facility Name: EPA ID Number:
Street Address: City:
5aU l«A<.
Zip:
County: Contact Person: Telephone #:
Generator Status: Number of Employees: Date of Visit:
Evaluators:
Other Personnel:
Waste Stream/Generation Process Estimated Generation Rate Per
Month
Hazardous Waste Code
Estimated Quantity of Hazardous
Waste Generated Per Month
A/fk
Date:
RECEIVED BY:
Name: (Printed) \
Title: -VAoL^Or Mo^a^ ^(
DSHW REPRESENTATIVE:
Title: Environmental Scientist 5^