DSHW-2024-007479

UteDepartment of E nvi ronmeneQual ity
Division of Solid and Hazardous Waste
P.0. Box 144880
Salt Lake Gity, Utah 841144880
Phone [phone]
Fax [phone]
SMALL BUSINESS ASSISTANCE PROGRAM
FACILITY INFORMATION FORM
Faciritv Name: sq-r s{^(F'RcE EtotoE[(trr6 TE<q EPA lD Number:ptr-( oooDO 6513
streetAddress' L{ Z. S d E r < A(frt frqO fU6 s?t'$y(E crr{='B.t ruo
county: fr(f [fiKL Contact Percon:Telephone #:
Generator Status
= Ct O Sr9 Number of Employees:Dateof vis*'Dc+. [1 , zo[ \
Evaluators' E g$,p^l-l
Other Perconnel:
Waste Stream/Generation Process Estimated Generation Rate Per
Month
Hazardous Waste Gode
cI.-. 0 5q_0
v.f; Ci -p dto eD
J
Estimated Quantity of Hazardous
Waste Generated Per Month
Date' Dct. ll l ?o l\
REGEIVED BY:DSHW REPRESEN
Name: (Printed)Name: (Printed)
Signature:Signature:
Title:Title: Environmental