B Does this facility Produce, Store or UseEnvironmental Hazardous Substances onTable A in a pure or mixture state:Darken either yes or no box

1. in any quantity? Yes No

2. above thresholds? Yes No

NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION

COMMUNITY RIGHT TO KNOW SURVEY FOR 2009 For State and Federal Community Right to Know Reporting

Please type or print legibly. THIS PAGE MUST BE COMPLETED, SIGNED, AND RETURNED.

See instructions if information on these forms is incorrect.

A Facility Location - Street, City, State, Zip and CountyMUST BE PROVIDED

C Briefly describe the current operations or businessconducted at this facility:

D Number of employees at facility

E Number of facilities in New Jersey

F Federal EINPlease verify

G If you are claiming an R&D labexemption for this facility, enteryour approval number.

Please indicate the reason for changing this information[ ] this facility moved [ ] additional facility[ ] correction to existing location

PART 1

1 2 3 4 5 6 0 0 0 0 0 812310

These 11 digits are your CRTK Facility ID Number which is assigned to you

2 2 1 2 3 4 5 6 7 2 0 1 7

Your FEIN (Tax) ID Number

택스 번호

2 2 1 2 3 4 5 6 7

If you are

1. 2008 년도에 하루라도 펄크보유량이 36.76갈론 (500 파운드 ) 이 넘었을때에는 , check ‘yes’ to #1 and #2. And must fill out Part 2

2. 2008 년도에 하루라도 펄크보유량이 36.76 갈론 (500 파운드 ) 넘지않았을때에는 , check ‘yes’ to #1, ‘No’ to #2

Please specify,

1. PERC Dry Cleaning,

2. Hydro-Carbon Dry Cleaning

3. CO2 Dry Cleaning

4. Green Earth Dry Cleaning

5. Rynex Dry Cleaning

6. Dry Solv Dry Cleaning

7. Wet Cleaning

8. Drop Store

Please leave as blank

기이 안함

# of people on payroll

보고하는 종업원 수

# of dry cleaners you own in NJ

뉴저지에 소유한 가게 숫자

Instructions of Community Right to Know Survey for 2009

Due by March 01, 2010

Workshop will be held on Jan. 21 and Feb. 1, 2010 at NJDEP Building in Trenton

Reminder : You must fill out Item I and Item J, also.

Item# I, J 도 기입하여야 함

This information will be pre printed

Please check for errors and correct

This information will be pre printed

Please check for errors and correct

H ReservedPERC Dry Cleaning

51x

x펄크기계가없는 시탁소는 ‘ No’ to #1 and #2

CONTAINER CODES AND DESCRIPTIONS

BA Bag DP

Plastic drumBG Bottles or jugs (glass) DS

Steel drumBN Tote bin EE

Electrical equipmentBP Bottles or jugs (plastic) HV

HVAC equipmentBT Battery OT

Other (describe)BX Box RC

RailcarCB Carboy SI

SiloCN Can TA

Above ground tankCY Cylinder TB

Below ground tankDF Fiber drum TI Tank inside building

TW

Tank Wagon

INVENTORY RANGE CODES 1

20 10 million pounds or greater19 1,000,000 to 9,999,999 pounds18 500,000 to 999,999 pounds17 100,000 to 499,999 pounds16 25,000 to 99,999 pounds15 10,000 to 24,999 pounds14 1,000 to 9,999 pounds13 500 to 999 pounds12 100 to 499 pounds11 10 to 99 pounds10 1 to 9 pounds09 Less than 1 pound1NOTE: Please see instructions for gallon

and cubic feet conversion factors

STORAGE TEMPERATURE AND PRESSURE CODES

Pressure01 Ambient* pressure02 Greater than ambient pressure03 Less than ambient pressure

Temperature04 Ambient temperature05 Greater than ambient temperature06 Less than ambient temperature but not

cryogenic (freezing conditions)07 Cryogenic conditions (less than -200 C)*Ambient means "normal, " "surrounding," or "room"conditions.

TETRACHLOROETHYLENE1810

127-18-41897

X X

X

TI13133650104

Reminder : This page must be filled out by PERC users with more than 500Lbs (36.76 gallons) in the facility on any given day. (include the PERC inside of the machine)

In the dry cleaning machine

Reminder : PERC Inventory Range Codes (on any given day)(1 년중 하루라도 )

If you have more than 500Lbs (36.76 gallons) and less than 1000Lbs (73.53 gallons) of PERC, use Range Code 13 ( 펄크보유량이 36.76 갈론 이상 75.53 길론 미만 일때에는 13 을 쓰세요 )

If you have more than 1000Lbs (73.53 gallons) of PERC, use Range Code 14 ( 보유량이 75.53갈론 이상 일때는 14 를 쓰세요 )

Instruction of Community Right to Know Survey for 2009 PART2

Reminder : ‘Tetrachloroethylene’ is another name for PERC

X

Reminder : Non-Hazardous Dry Cleaning Solvents are not reported on the CRTK Survey. Check off “No” to questions “1” & “2” in Box “B” on the previous page and then submit the CRTK back to the NJDEP. (Non-Hazardous Dry Cleaning Solvents are: Hydro-Carbon; Rynex; GreenEarth; Dry Solv; CO2 and Wet Cleaning.)