Attachment_14_-_Facility_Profile_Sheet.pdf

SP4530-13-R-0004

ATTACHMENT 14

FACILITY PROFILE SHEET

1. Facility Data:

Facility Name: ________________________________________________________________

Address: ____________________________________________________________________

Facility Representative(s): ______________________________________________________

Telephone Number: _________________________ Fax Number: _____________________

Email: _____________________________________________________________________

Principle Owner(s): ___________________________________________________________

2. DRMS Facility BOSS ID# ___________________________ . (Provide number if facility has been previously approved by DRMS.)

3. For all permits, authorizations, and licenses that authorize the transportation of hazardous waste, provide the following information:

Permitting Authority Permit Number Expiration

Date Country Waste

Authorized

* Note: table continued on page 2 , if necessary

4. For each waste that will be processed through the facility, identify the waste, treatment process and CLIN number.

Waste Treatment Process CLIN Number

* Note: table continued on page 3 , if necessary

Continuation page for item #3.

Permitting Authority Permit Number Expiration

Date Country Waste Authorized

Continuation page for item #4

Waste Treatment Process CLIN Number