LEGAL NAME OF CORPORATE ENTITY:



|LEGAL NAME OF CORPORATE ENTITY: |

|Claw Dry Cleaners |

|MAILING ADDRESS: |

|139 Anywhere Street |

|CITY: |STATE: |ZIPCODE: |

|Matthews |North Carolina |28105-0001 |

|CORPORATE CONTACT PERSON: |TITLE: |

|Sami Claw |Owner |

|TELEPHONE: |FAX: |E-MAIL: |

|704-336-5500 |704-336-4391 |MCDEP01@Co.Mecklenburg.NC.US |

|SITE NAME (if different from above): |

|Claw Dry Cleaners - Downtown |

|MAILING ADDRESS: |SITE ADDRESS: |

|139 Anywhere Street |700 North Nowhere Avenue |

|CITY: |CITY: |COUNTY: Mecklenburg |

|Matthews |Charlotte | |

|STATE: |ZIP CODE: |STATE: |ZIPCODE: |

|North Carolina |28105-0001 |North Carolina |28202-2222 |

|ONSITE CONTACT PERSON: |TITLE: |

|Butch Rocker |Shift Supervisor |

|TELEPHONE: |FAX: |E-MAIL: |

|704-336-5500 |704-336-4391 |MCDEP01@Co.Mecklenburg.NC.US |

| | | |

| | | |

|IS THERE DRYCLEANING EQUIPMENT ON-SITE? |( ( ) YES |( ) NO, the location to which we take clothes is: |

| | |___________________________________________________________________ |

|Circle the appropriate equipment type and fluid type |

|Equipment |EQUIPMENT |DRYCLEANING |GALLONS (and TYPE if OTHER) |INSTALLATION |RATED CAPACITY |

|ID |TYPE |FLUID |OF FLUID USED |DATE | |

| | | |IN 2003 | |POUNDS PER LOAD |

|(Example) |Dry-to-Dry |PERC |98 |1995 |35 lbs |

|A-1 | |STODDARD SOLVENT | | | |

| |Transfer |OTHER | | | |

|(Example) |Dry-to-Dry |PERC |700 |1959 |90 lbs |

|A-2 | |STODDARD SOLVENT | | | |

| |Transfer |OTHER | | | |

|New Machine |Dry-to-Dry |PERC |4002 |2004 |70 lbs |

| | |STODDARD SOLVENT | | | |

| |Transfer |OTHER | | | |

| |Dry-to-Dry |PERC | | | |

| | |STODDARD SOLVENT | | | |

| |Transfer |OTHER | | | |

| |Dry-to-Dry |PERC | | | |

| | |STODDARD SOLVENT | | | |

| |Transfer |OTHER | | | |

| |Dry-to-Dry |PERC | | | |

| | |STODDARD SOLVENT | | | |

| |Transfer |OTHER | | | |

|Does someone live directly above or beside your facility? |( ) Yes ( ( ) No |

|Was there a Drycleaning Establishment that used perc at this location? |(( ) No ( ) Yes, but perc was last used in this year: _____________ |

|The undersigned certifies that all information and statements provided in the application, based on information and belief formed after reasonable inquiry, are true, |

|accurate, and complete. |

| |

| |

|_______________________________________________________________________________________________ |

|Signature of responsible company official Date |

|RESPONSIBLE COMPANY OFFICIAL: (Print Name) |TITLE: |

|Sami Claw |Owner |

| |

|MAILING ADDRESS: 139 Anywhere Street |

|CITY: |STATE: |ZIPCODE: |

|Matthews |North Carolina |28105-0001 |

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For office use only. Date received.

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