DSHW-2011-010223 - 0901a0688028b010

OMB# 2050-0024; Expires 11/30/2011
SEND
COMPLETED
FORM TO:
The Appropriate
State or Regional
Office.
United States Environmental Protection Agency
RCRA SUBTITLE C SITE IDENTIFICATION FORM
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NOV 1 •
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1. Reason for
Submittal
MARK ALL
BOX(ES) THAT
APPLY
Reason for Submittal: ^^0/ (. 0^ ^
• To provide an Initial Notification (first time submitting site identification information / to obtain an EPA ID number
.^ior this location)
provide a Subsequent Notification (to update site identification information for this location)
• As a component of a First RCRA Hazardous Waste Part A Permit Application
• 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 kg of acute hazardous waste spill cleanup in one or more months of the report year (or State equivalent
LQG regulations)
2. Site EPA ID
Number EPAIDNumber |MtT]KllDl Pi Ql QOl^^lfl Rk3 I
3. Site Name Name: SKAF^^H 1^/001/0^6/1,^06 TEC^
Hg^6 ^^\^ /9/^>An $T/^o^O 4. Site Location
Information
Street Address:
City, Town, or Village: kaKg <^''^'f
state: Country:
County:
• Private LJ County • District • Federal D Tribal D Municipal
ZipCode: ll4>
5. Site Land Type •
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state • Other
6. NAICS Code(s)
for the Site
(at least 5-digit
codes) B. I I I I I I
I I I I I I
I I I I I I
7. Site Mailing
Address
Street or P.O. Box:
City, Town, or Village:
State: Country: Zip Code:
8. Site Contact
Person
First Name: Ml: Last:
Title:
Street or P.O. Box:
City, Town or Village:
State: Country: Zip Code:
Email:
Phone: Ext.: Fax:
9. Legal Owner
and Operator
of the Site
A. Name of Site's Legal Owner: Date Became
Owner:
Owner Type: • Private • County • District • Federal •Tribal • Municipal •state • Other
Street or P.O. Box:
City, Town, or Village:
State: Country:
B. Name of Site's Operator:
Phone:
Zip Code:
Date Became
Operator:
^Type*"*^ • Private • County •District •Federal • Tribal •Municipal •state •other
EPA Fomi 8700-12, 8700-13 A/B, 8700-23 (Revised 11/2009) Paget of
: I: V,//' . .: "
EPA ID Number OMB#: 2050-0024; Expires 11/30/2011
12. Notification of Hazardous Secondary Material (HSM) Activity
^Y'^Ci''N • Are ybu 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
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 directiy 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 Pennit Application, all owner(s) and operator(s) must sign (see 40 CFR 270.10(b) and 270.11).
Signature of legal owner, operator, or an
authorized representative
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