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Form Approved OMB No 2050.0028 F+wr<t-.20.88 <br />Please orrel or type w,Ih ELRE fl (12 cNr¢rers per mcAl m the ."haled areas.01 GSA No 0146.EPA-0r <br />United States Environmental Protection n Please (star to the Instructions for <br />Washington, DC: I Fibng Notilication before completing <br />this form. The mlormationrequesteati <br />here is required by law (Secon <br />A"" <br />4''+ Notification of Hazardous aste Activity 30f0ofNeResource Consanerian <br />and Recovery Act). <br />For Official Use Only <br />Comments <br />III <br />I <br />IIII <br />C!IIiIII <br />Installation's EPA ID Number <br />Approved <br />Date Received <br />(yr. ma. daYJ <br />OIOI�r <br />I�i <br />F <br />I. erne of Installation <br />011EI<ICI� I I I I I <br />I I I I <br />I <br />(---I�-IAI51s <br />It. installatitin Mading Address ' <br />Street or P.O. Box <br />I� <br />I�IQ1 <br />ol I <br />Iult <br />INI <br />IR <br />i I 5 4, <br />3 <br />City or Tawn <br />S�ttaattfee <br />ZIP Code <br />M. Location of Installation <br />Street or Route Number <br />City or Town <br />ZIP Code <br />%State <br />/ y <br />V. Installation Contact <br />Name and Thle last first, and* rirlel Phone Nuber area code and number <br />a�2 L E HI. RIE4� c �-�m1 �436 /76Z— <br />V. Ownersfti <br />A. Name of Installation's Legal Owner B. Type of Ovenershi enter code <br />Z- <br />I IqIS 5 1 1E <br />�@164� P <br />R <br />Vl. T of Regulated Waste ActivityMark 'X' in the a o riare boxes. Refer to instructions. <br />A. Ha:ardoua waste Actyrry <br />B. Used OR Fuel Activities <br />Generator III b.lsssthan 1,000 kg/mo. <br />ansportx <br />)!I OffSwcif"eon V;swdP4LFuel y I <br />, . .lN,ar .?rraie bobo awlLi L- <br />eew/Stour/Disposar <br />U a. Generator to Burner Lnd.rgroundartin <br />7LJ2- <br />w Burn HaznrSotts Waste Fuelrn.r x and mar* aa,raor are boxes 6.47.el <br />' <br />On <br />Cl:*. Generator Marketing to Sumer <br />ye.7S, tea ld rl Fwl Marketx /w ant, ur(tOrr <br />Uu We'd Frtftt 1 Meats ltfa,SpecfiC?u¢, CI31U li V <br />❑ b. Other Marketer <br />❑ C. Sumer <br />V11. Waste Fuel BUMing: Type of Combustion Devic'a (am"X- in &II&pproprists, box" far w'car.nros �tb'usiloo'dwKHrlin' <br />avfwrh hazardous waste fua/ or off•specrlication usad oil fuel is bwrlad See nsuu[tiorss for defimdorls of combustion daviees.J <br />C] A. Utility Boiler CIB. industrial Boiler ❑ C. InCttsaial Furnace <br />Vlll. Mode of Transportation (trans orters only — enter'X' in the 3pprO boxes <br />/riare <br />❑ A. Air ❑ B. Rail , ❑ C. Highway ❑ M D. Water ❑ E. Oa (spocdyl I (p3 — Washington <br />' X. First or Subse q uent Notification <br />IV 'X" in the appropriate box to indicate whether this is your installnion's tint notification of hazardous vvasta activity or a subsequent <br />r:. anon. If this is n,aiwur first gotlfigaimn, enter your installation's EP D Number in the space provided below. <br />61I/9D/�`/{� <br />9 C. Installation's EPA ID Number <br />�atdicatwn ❑ B. Subsequart 01p i�a ti rr��/car(( tart m CJ 0 <br />0a_/�INInit7SAa/Fn/V/ 11 /A11i4 .r <br />EPA Form 00.12 (Rw. 1 t• I Prevrous Wi lon is oosolete. Continue an revarse <br />