DSHW-2010-036303 - 0901a068801b596b

OMB# 2050-0024; Expires 11/30/2011 HAND DELIVERED
SEND
COMPLETED
FORM TO;
The Appropriate
State or Regional
Office.
AUG 0 2 2010
United States Environmental Protection Agency
RCRA SUBTITLE C SITE IDENTIFICATION FORWUTAH DIVISION J
SOLID & HAZARDOUS
1. Reason for
Submittal
MARK ALL
BOX(ES) THAT
APPLY
Reason for Submittal: ^0 1 0 - OQI QO
• To provide an Initial Notification (first time submitting site identification information / to obtain an EPA ID number
for this location)
©To provide a Subsequent Notification (to update site identification information for this location)
O As a component of a First RCRA Hazardous Waste Part A Permit Application
p] As a component of a Revised RCRA Hazardous Waste Part A Permit Application (Amendment # )
• As a component of the Hazardous Waste Report (If marked, see sub-bullet below)
•site was a TSD facility and/or generator of >1,000 kg of hazardous waste, >1 kg of acute hazardous waste, or
>100 kq of acute hazardous waste spill cleanup in one or more months of the reoort vear (or State eauivalent
LQG regulations)
2. Site EPA ID
Number EPAlDNumber |U |TlO 13 1 15 1 ^ l|3 | H | 0|
3. Site Name Name:^,U*.^,^ t ^CiUlM^MT Sei^VflCg^ ^^U^.^.
4. Site Location
Information
Street Address: U3E: ST 3.106 ^D^TK 4. Site Location
Information City. Town, or Village: kl'H'^ ^ C V T ^ County:
4. Site Location
Information
State: (A 1 '^H Country: lAO/T Zip Code: oH { i ^
5. Site Land Type iSQ'rivate • County • District • Federal • Tribal • Municipal • State • Other
6. NAICS Code(s)
for the Site
(at least 5-digit
codes)
A. ift 11 1 \ 13 1 \ 1 Ol c. • 1 1 1 1 1 1 1 6. NAICS Code(s)
for the Site
(at least 5-digit
codes) B. 1 D. 1 1 1 1 I 1 1
6. NAICS Code(s)
for the Site
(at least 5-digit
codes)
7. Site Mailing
Address
Street or P.O. Box: 3>a'^<„ H-\Q..^ 4t S 7. Site Mailing
Address City. Town, or Village:
7. Site Mailing
Address
State: Country: ^ Zip Code:
8. Site Contact
Person
First Name: d.r ^\ <^ Ml: Last: A*^^^ c50v^ 8. Site Contact
Person Title: ^ ^^^\/\C<L. ^^av^aqG^
8. Site Contact
Person
Street or P.O. Box: uAC aS X~tfi-lAA
8. Site Contact
Person
City. Town or Village:
8. Site Contact
Person
State: Country: Zip Code:
8. Site Contact
Person
Email:
8. Site Contact
Person
Phone: ^^01-^14-03^^ Ext.: Fax:
9. Legal Owner
and Operator
of the Site
A. Name of Site's Legal Owner: Date Became
Owner: 9. Legal Owner
and Operator
of the Site Owner Type: • Private • County • District • Federal • Tribal • Municipal • State • Other
9. Legal Owner
and Operator
of the Site
Street or P.O. Box:
9. Legal Owner
and Operator
of the Site
City, Town, or Village: Phone:
9. Legal Owner
and Operator
of the Site
State: Country: Zip Code:
9. Legal Owner
and Operator
of the Site
B. Name of Site's Operator: [{^^ E>Q.U v7''^'V)^c{ <.«- S
Date Became
Operator:
9. Legal Owner
and Operator
of the Site
°Type*°'^ Private • County •District •Federal •Tribal •Municipal • State • Other
EPA Form 8700-12, 8700-13 AIB, 8700-23 (Revised 11/2009) Pagel of
EPA ID Number OMB#: 2050-0024; Expires 11/30/2011
0. Type of.Regulated Waste Activity (at your site)
Mark "Yes'"br "Nb" fo'rialfcurrent activities (as of the date submitting the form); complete any additional boxes as instructed.
A. Hazardous Waste Activities; Complete all parts 1-7.
Y 1. Generator of Hazardous Waste
If "Yes", mark only one of the following - a, b, or c.
• a. LQG: Generates, in any calendar month, 1,000 kg/mo
(2,200 lbs./mo.) or more of hazardous waste; or
Generates, in any calendar month, or
accumulates at any time, more than 1 kg/mo (2.2
Ibs./mo) of acute hazardous waste; or
Generates, in any calendar month, or
accumulates at any time, more than 100 kg/mo
(220 lbs./mo) of acute hazardous spill cleanup
material.
• b. SQG: 100 to 1,000 kg/mo-(220 - 2,200,lbs./mo),of non-
^. acute hazardous waste.^ ,
c. CESQG: Less than 100 kg/mo (220 Ibs./mo) of non-acute
hazardous waste. ' '," . • j. - '• •
• 2. Tra
If"
Transporter of Hazardous Waste
Yes", mark all that apply.
• a. Transporter
• b. Transfer Facility (at your site)
YD
YD
N K
N j^4. Recycler of Hazardous Waste
3. Treater, Storer. or Disposer of
Hazardous Waste Note: A hazardous
waste permit is required for these activities.
' n N 8^5. Exempt Boiler and/or I
i •. If "Yes", mark all that i
YDN ^
YD N^jS
Y • N jS^
If "Yes" above, indicate othei-generator activities. ;
d. Short-Term Generator (generate from a short-term or one-
time event and not from on-going processes). If "Yes",
provide an explanation in the Comments section.
e. United States Importer of Hazardous Waste
f. Mixed Waste (hazardous and radioactive) Generator
Y • N^^
Y • N "
- Industrial Furnace
; apply.
a. Small Quantity On-site Burner
Exemption
• b. Smelting, Melting, and Refining
Furnace Exemption
6. Underground Injection Control
7. Recieives Hazardous Waste from Off-site
B. Universal Waste Activities; Complete all parts 1-2.
Y • N^ Large Quantity Handler of Universal Waste (you
accumulate 5,000 kg or more) [refer to your State
regulations to determine what is regulated]. Indicate
types of universal waste managed at your site. If "Yes",
mark all that'apply.
a. Batteries
b. Pesticides
c. Mercury containing equipment
d. Lamps
e. Other (specify)
f. Other (specify)
g. Other (specify)
•
•
•
•
•
•
•
Y • Destination Facility for Universal Waste
Note: A hazardous waste permit may be required for this
activity.
C. Used Oil Activities; Complete all parts 1-4.
Y • N H^''- Used Oil Transporter
If "Yes", mark all that apply.
• a. Transporter
• b. Transfer Facility (at your site)
Y • N 2. Used Oil Processor and/or Re-refiner
If "Yes", mark all that apply.
• a. Processor
• b. Re-refiner
• N Off-Specification Used Oil Burner
Y • N 4. Used Oil Fuel Marketer
(^ If "Yes", mark all that apply.
Y\ a. Marketer Who Directs Shipment of
Off-Specification Used Oil to Off-
Specification Used Oil Burner
• b. Marketer Who First Claims the Used
• • Oil Meets the Specifications
EPA Form 8700-12, 8700-13 A/B, 8700-23 (Revised 11/2009) Page 2 of
EPA ID Number OMB#: 2050-0024; Expires 11/30/2011
D. Eligible Academic Entities with Laboratories—Notification for opting into or withdrawing from managing laboratory hazardous
wastes pursuant to 40 CFR Part 262 Subpart K
• You must check with your State to determine if vou are eliaible to manage laboratory hazardous wastes pursuant to 40 CFR Part
262 Subpart K
01. Opting into or currently operating under 40 CFR Part 262 Subpart K for the management of hazardous wastes in laboratories
See the item-by-item instructions for definitions of types of eligible academic entities. Mark all that apply:
• a. College or University
O b. Teaching Hospital that is owned by or has a formal written affiliation agreement with a college or university
Oc. Non-profit Institute that is owned by or has a formal written affiliation agreement with a college or university
C 2. Withdrawing from 40 CFR Part 262 Subpart.K for the management of hazardous wastes in laboratories
11. Description of Hazardous Waste
A. 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.
B. Waste Codes for State-Regulated (i.e., non-Federal) Hazardous Wastes. Please list the waste codes of the State-Regulated
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 (Revised 11/2009) Page 3 of
EPA ID Number OMB#: 2050-0024; Expires 11/30/2011
12. Notification of Hazardous-Secondary Material (HSM) Activity
Y • N GJ^Are you notifying under 40 CFR 260.42 that you will begin managing, are managing, or will stop managing hazardous
/^secondary material under 40 CFR 261.2(a)(2)(ii), 40 CFR 261.4(a)(23), (24), or (25)?
If "Yes", you must fill out the Addendum to the Site Identification Form: Notification for Managing Hazardous Secondary
Material.
13. Comments
J
•k
14. Certification. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properiy 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 gathering 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. For the RCRA
Hazardous Waste Part A Permit Application, all owner(s) and operator(s) must sign (see 40 CFR 270.10(b) and 270.11).
Sicmature of legal owner, operator, or an
ithorized Representative
Signi
a(jtft«
Name and Official Title (type or print) Date Signed
(mm/dd/yyyy)
EPA Form 8700-12, 8700-13 A/B, 8700-23 (Revised 11/2009) Page 4 of