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HomeMy WebLinkAbout12999 ALR000061705 021 10-16-2020 CORR JDH 870-12 ^'l rA Please tint or eln the unshaded areas onlyn I II � j '— lY Lam'\\/ AOEm roan e]eg s etl019 Please rater to the AOEM Pr Onlyl Form 8700-12 instructions before Notification of Regulated Form Information instructions beforeA©EM ,t complain, this form. Waste Activity ,r OCTB mermatinn requested L—Ih here is requlmd by law if 1 I , i 3010 of the Resource Conservation and f Recovery Ace. Alabama Department of Environmental Management I. Notification Cless(Check appropriate box and enter ID number,if known.) 'Ay r "'- Facilit 's EPA ID Number ❑ Initial ® Annual ❑ Other A `R 0000ilI.JOS Notification Notification I•••ithe=ri^ne I'� II. Operating Name of Facility Include company and specific site name WN THGnt\As (Q 'i - c Operating Name of Facility Continued III. Change of Facility Name? No Yes © (IrVes, enter previous name of Facility below.) IV. Location of Facility(Physical address not P.O.Box or Route Number) Street -702. Geemo t toGE Bono City or Town State I Zip Code Cr_al.lroN L 11 mo4s _ V. Geographic Location See Instructions Method Latitude Longitude fc FO— FS— 3 9r . 8-Vackcks N 0 8 b . Ill 76\ 1 W County Name C u t I_Tbp-7 VI. Facility Contact Person to be contacted regarding waste activities at site Name First Last t �` CHOMPS Job Title Phone Number Area Code and Number �R�StD fJs(- _C'5 7SS _ 2fe 10 Ext Contact Email Address(optional) bil\ w� Flno Nws O.\. coM VII. Facility Mailing Address See lnsbuctlons Street or P.O.Box P O -PJOX 8R"a City or Town State ZIP Code VIII.Descrl tion of Facility Processes See instructions for NAICS Code listings) A. Facility Process In the space provided below,describe each of the processes at your facility that produce Regulated Wastes. 1. USES Ott_ 2. 3. 4. 5. B. NAICS Codes: Enter the North American Industry Classification System(NAICS)Code of the overall production,distribution,or service activity of your site. Also,provide any additional NAICS Codes that describe the s ecific industrial processes that are used. Prima 2 3 4 5 t-124 '7 20 ADEM Form 8700-12 MS 812019 Continued on Next Page Please Print ortwo in the unshaded areas oniv euEM roan ere..v M5 e2019 IX. Ownership See Instructions A. Legal Name of Facility �r.�.":7 vharr,Ay 011— C.o ZNC_ B. Name of Facility's Leg Nal Owner Email Address w��1au MS 0., •CONN W•N•—f 1 "oM O.S. 0• �eo Z.Nta Street, P.O.Box or Route Number P.O . "goX Sao City or Town I State Zi Cotle CLAt. -rm," AL 3504b _ Phone Number(Area Code and Number) C.Land D.Owner E.operacr Change or Owner Data Changed T T type intlicalor Month Da Year es ri he F. Name of Facility's On-Site Operator Email Address SArv\e AS �3oV Street, P.O. Box or Route Number City or Town State Zi Cade Phone Number(Area Code and Number) Eat. G. Name of Facility's Parent Company SAN.e RS R iavlz Street,P.O. Box or Route Number City or Town State Zi Cotle Phone Number(Area Code and Number) Changeofowner Date changed mdleetor Month Da Year Ext. ea ✓ No H. Name of Facility's Property Owner SA„Ne As A3cv Street,P. O. Box or Route Number City or Town State I Zip Code Phone Number(Area Code and Number) Change of owner Data Changed Ind roabr Mon No Year Exl vea ✓ No FacI'll 's EPA ID Nu mber ADEM Form 8700-12 M5 812019 AL.R0000 (c 11 o S (Continued On Next Page) page 2 Please Print or Woo In the unshaded areas only, ADEM Form nap-u Me arsola X. Certification Status Note: Pursuant to ADEM Admin.Code chap.335-1-6,all Notification Forms submitted to the Department must include the appropriate certification fee in order to be complete. During at least 1 month of the next 12 months this facility will operate and/or me ma - (Check all that apply) A. Hazardous Waste Activities(Attach Schedule A) C. Universal Waste Activities(Attach Schedule C) 1. ❑Large Quantity Generator>2,2001bs/month 1. El Universal Waste Transporter L 1,000 kg/month) 2. ❑ Large Quantity Handler?11.020 Its (15,000 kg) 2. ❑Small Quantity Generator between 221 and 2,199 lbs/month 3, ❑ Small Quantity Handler H 1,0201bs (s,5,000 kg) (between 101 and 999 kg/monm) 4. ❑ Universal Waste Destination Facility 3. ❑Very Small Quantity Generator a 220 Ibs/month (c —]Are you notifying under ADEM Admin.Code 100 kg/month) D. (Note:Household peneraWn is exemprunder3351F2-.ef(4)(D)1.) r.335-14-1-.03(22)that you will begin managing,are 4. ❑ Not a generator(Schedule A not required for this option) managing,or will stop managing hazardous secondary 5. Trans ortedfrensfer Facility material under ADEM Admin.Code m.335-14-2-.01(4)(a) ❑ P y (23)&(24)?If yes,you must rill out the addendum. 6.BTeatmem Facility Treatment Facility—Combustion E.❑Episodic Generation-Are you notifying under 7. —Other than Combustion ADEM Admin.Code r.335-14-3-.13?Please see instructions. You may only be required to submit the 8. ❑ Storage Facility lI�--IaI�d� dendum. 9.❑ Disposal Facility F.are you an BOG or LOG notifying of consolidating VSQG hazardous waste under ADEM min.Code r. 14-3-.01(7)(f)?If yes,you must fill our the addendum. B. Used Oil Activities(Attach Schedule 8) G. Pharmaceutical Activities 1.❑ Generator(>25 gallons/month) 1. Operating under Subpart P for the management of 2.® Trensporter(Transfer Facility hazardous waste pharmaceuticals.Mark only one. 3. ❑ Processor/Re-refiner a.❑Heaahwm facility 4.❑ Fuel Marketer b.[—]Reverse Distributor 2, ❑Withdrawing from operating under Subpart P. You 5, ❑ Burnermay only withdraw ifyou are a healthcare(acility that is no longer an LOG or SOD. Any ADEM Form 8700-12 submitted without all appropriate waste schedules and certification fees will not be processed. XI. 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 properly 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 fine and Imprisonment for knowing violations. Signature Name and Official Title (Type or Print) Date Signed 81�r_—T14OAkAS f2cslOFAY� 07Oe"rtow IXII.Comments Date Processed Iror OMcal Use only) Mail completed tone,a check or mono order for all a Alabama Department of Environmental Management p y attachments t certification Land Division (e65,and all necessary schedules and 8ttaphmenfS to: P.0.Box 301463 Mont ome ry,AL 36130.1463 ADEM Form 8700-12 M5 8/2019 Facilitnins EPA ID Number A Page 3 Li?,QCXD00 t'105 Please print ort , a in the unshaded areas onIv ADEM Form 8100.12 Ms e120215 XIII.Additional Information Sheet Facility's EPA ID Number ADEM Form $700.12 M5 XI2020 fkL Q0000(p n O S Page 4 Please print or time in the unshaded areas..1v AosM lone ull iz Ms e¢ate Please refer to the (for ADEM Un only) ADEM Fomn e70a12 ADEM Form 8700-12 Roush Form °aw°a°n• error° Schedule B aatng this rm fa . Information rosuestM hem is required by law Certification of Used Oil (§3010 of the Resource gen":y`d°o end Management Recoya Ac I. Type of Used Oil Management Activity See instructions isA.Used Oil Generator/Collector C.Off -Specification Used Oil Fuel Burner 1.On-site Generation Only 1.Bums Only Off-Specification Used Oil Generated Do not count used oil when calculating hazardous waste generator status. On-Site 2.Do-it-yourself Collection Center(i.e.,from off-site source) 2.Indicate Type(s)of Devices ® 3.Collection Center(i.e.,from off-site source) a.Utility Boiler E] c.Industrial Furnace 4.Aggregation Point(i.e.,from off-site source) b.Industrial Boiler B. Used Oil Fuel Marketer D.Used Oil Transporter tt 1.Directs Shipment of Used Oil to Off-Specification Burner 1.Only For Used Oil Generated On-site F-1 2.First Claims Used Oil Meets Specifications 2.Operates a Transfer Facility 3.Burns Only Used Oil Generated On-site as On-Specification Fuel E. Used Oil Processor/Re-refiner tt NOTE:A permitnt required for this activity. Contact 334 270-5637 for more information II. Used Oil Generation During a typical year,this facility collects/generates 22S.000 of Used Oil. (quaraftly inpounds) III. Used Oil Fuel Marketer During a typical year,this facility markets D of Used Oil. uantit inpounds) IV. Used Oil Burner During a typical year,this facility burns of Used Oil. (quantity in pounds) V. Used Oil Transporter During a typical year,this facility transports 10 of Used Oil. (quantity inpounds) VI. Used Oil Processor/Re-refiner During a typical year,this facility processeslre-refines O of Used Oil. uantit inpound,) Note: In order for this schedule to be accepted by ADEM, it must be attached to a completed Notification of Regulated Waste Activity, ADEM Form 8700-12, and must include the appropriate certification fees, as required by ADEM Admin. Code chap. 335-1-6. Comments: ADEM Form 8700-12 MS 812019 Facilit 's EPA ID Number Page 1 I� r�t-(Z 0000fo t'70 j