Get OH EPA 0316 2002-2024

Parent Company or Public Entity Identification Name of Parent Company 30 char max Address 30 char max Negative First time filer SERC c/o Ohio EPA Lazarus Government Center County Local Emergency Planning Committee Information Coordinators City 25 char max State Local Fire Department within the jurisdiction of the facility NOTE If marked ownership change in box located in upper right-hand corner please provide Zip Code HC Reported Where to send completed forms Important Type or print Read Instructions before completing form. County No change from last year s Exempt Ownership change Operating Division Name 30 char max a Name of previous parent company/owner if known Facility Name 30 char max Name Street Location 30 char max Address H City State Zip Mailing Address if different from Street Location 30 char max O 2. Ohio State Emergency Response Commission Please check as applicable c/o Ohio EPA Lazarus Government Center 50 West Town St* Suite 700 P. O. Box 1049 Columbus Ohio 43216-1049 Check if form is identical to form submitted last year Facility Identification Form For filing Date / / / 1. 3-Facility Dun Bradstreet a* NAICS b. 24 Hr. Telephone Number Include Area Code Emergency Contact 30 char max Telephone Number Include area code Alternate Contact 30 char max Fire Department Name 25 char max Longitude Min* Sec* Deg. a* of Employees Air Permit Facility This Space for EPA use only O H a* Pretreatment a* NPDES Permit State Wastewater Facility RCRA Identification Latitude a* Check if list of Facility Permit numbers is attached* 3. Certification Read and sign after completing all sections. I hereby certify that I have reviewed the attached documents and that to the best of my knowledge and belief the submitted information is true and complete and that the amounts and values in this report are accurate based on data available to the owners/operator of this facility. 3. 1 Name and official title of owner/operator or senior management official at facility 3. 2 Signature EPA 0316 Rev* 10-02 Office Telephone Number Date Signed. Ohio State Emergency Response Commission Please check as applicable c/o Ohio EPA Lazarus Government Center 50 West Town St* Suite 700 P. O. Box 1049 Columbus Ohio 43216-1049 Check if form is identical to form submitted last year Facility Identification Form For filing Date / / / 1. 3-Facility Dun Bradstreet a* NAICS b. 24 Hr. Telephone Number Include Area Code Emergency Contact 30 char max Telephone Number Include area code Alternate Contact 30 char max Fire Department Name 25 char max Longitude Min* Sec* Deg. a* of Employees Air Permit Facility This Space for EPA use only O H a* Pretreatment a* NPDES Permit State Wastewater Facility RCRA Identification Latitude a* Check if list of Facility Permit numbers is attached* 3. a* of Employees Air Permit Facility This Space for EPA use only O H a* Pretreatment a* NPDES Permit State Wastewater Facility RCRA Identification Latitude a* Check if list of Facility Permit numbers is attached* 3. Certification Read and sign after completing all sections. I hereby certify that I have reviewed the attached documents and that to the best of my knowledge and belief the submitted information is true and complete and that the amounts and values in this report are accurate based on data available to the owners/operator of this facility. .