DSHW-2024-007280

\rAO
Utah Department of Environmental Quality
Division of Solid and Hazardous Waste
P.O. Box 144880
Salt Lake City, Utah 841144880
Phone [phone]
Fax (801 ) 536 -0222
SMALL BUSINESS ASSISTANCE PROGRAM
FACILITY INFORMATION FORM
Facility Name:""' Dh \,*'] '-f(.. hyr{, L ccr t,^
EPA lD Number:
u-TR.00bbh \aob
Street Addressr nut UO ",^t;L-ac{O
\q*citv:*
o4,\ kkt Zip=kYtfl
County= SU Contact Person:Telephone #:
Generator Status:Number of Employees:Dateof visit: #q - L< " /a (z
Evaluatorsr ,r' 4l,ty P.,>tJ,---p*
Other Personnel:
N e-'\,;
v)
l
i,-1', tOA-.\/.t1.8) rr CLilfs ;r1a,T fu,nt"t',(p t-( V/
Waste Stream/Generation Process Estimated Generation Rate Per
Month
Hazardous Waste Code
C Ir;\ aA G.A \() t (;t i,, r-^.
"q"il 0,4-d &-A &*-da '\Lc= 1q>
S.-c\ YL
t{,x^l \B ic 'r\^\,.( ( .L
Estimated Quantity of Hazardous
Waste Generated Per Month
Date: 1 .7 { '" 't u
RECEIVED BY:DSHW REPRESEN ATIVE:
',1,
Name: (Printed)Name: (Printed)
Signature:Signature:
Title:Title:
{-{'l;