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Hazardous Materials/Waste Registration Form - Page 2 of 18 RECEIVE` D. Hazardous Waste Inventory Information (Hazardous Waste Generator Permit Appli n{""ent) Complete the table below for all waste inventory. Use additional pages if needed. "AN JOAQUIN COUN All ir'i n,' FnnGar_;:Mrry c , Ilaza rd Name of Treatment/Disposal Method(s) Max. Qty. Annual Qty. Location(s) Class Hazardous Waste (Definitions provided on bottom of page) (at any one time) Generated (see Section F) NONE Recycled on-site. ❑ gal_ [I gal. Treated on-site. ❑ lbs. ❑ lbs. ❑ Shipped off-site for recychng/treatment/disposal ❑ cu. ft. ❑ cu. ft. Recycled on-site. ❑ gal, 11gal. LJ Treated on-site. ❑ lbs. ❑ lbs. ❑ Shipped off-site for recycling/treatment/disposal ❑ cu. ft. I ❑ cu. ft. Recycled on-site. ❑ gal. ❑ gal. Treated on-site. El lbs. El lbs' ❑ Shipped off-site for recycling/treatment/disposal ❑ cu. ft. ❑ cu. ft. Recycled on-site. ❑ gal. ❑ gal, LJ Treated on-site. ❑ lbs. ❑ lbs. ❑ Shipped off-site for recycling/treatment/disposal ❑ cu. ft. ❑ cu. ft. Recycled on-site. ❑ gal, ❑ gal. Treated on-site. ❑ lbs. ❑ lbs. ❑ Shipped off-site for recyclinghreahnenddisposal ❑ cu. ft. ❑ cu, ft. Recycled on-site. ❑ gal, ❑ gal, Treated on-site. ❑ lbs. ❑ lbs. ❑ Shipped off-site for recycling/treatment/disposal ❑ cu. ft. ❑ cu. ft. E. Additional Disposal Information For the following questions, check the appropriate box: 1. Does this facility discharge process waste waters to sanitary sewer? ❑ Yes; ® No 2. Does this facility generate infectious/biomedical wastes? ❑ Yes; ® No 3. Does this facility store/handle radioactive materials? ❑ Yes; ® No F. Facility Site Plan/Storage Map Prepare and submit with this Registration Form a simple site map (see next page) which shows the following information: • North direction • Street(s) adjacent to facility • Location of storm drains • Electrical, water, and gas shutoff valves • Basic floor plan for each building containing hazardous materials/wastes which indicates building entrance(s) and hazardous material/waste storage locations (use grid locations or assign a code - A, B, C, etc. - to clearly identify each storage location for use in the above inventories). I declare that the above information is true and correct to the best of my knowledge. I agree to comply with all applicable regulations regarding storage, handling, and disposal of hazardous in rials an azardous or biomedical wastes. Steve Skanderson May 19, 2009 Owner/Operator's Name (Print) weer/Operator's Signature Date Definitions of Treatment/Disposal Methods Recycled on-site - The facility takes the waste or any constituent of the waste, treated or not, and reuses it on-site or ships it off-site as an Excluded Recyclable Material. Treated on-site - The facility employs any method, technique, or process which changes or is designed to change the physical, chemical, or biological character or composition of the hazardous waste or any material contained therein, or removes or reduces its harmful properties or characteristics for any purpose including, but not limited to, energy recovery, material recovery, or reduction in volume. (e.g. pH adjustment, evaporation, precipitation, filtration, distillation, compacting, etc.) If, after treatment, the material is reused at the facility, the "Recycled on-site" box in the waste inventory table should be checked. Shipped off-site for recycling/treatment/disposal - The facility sends the waste, or any hazardous treatment residual, to an off-site permitted treatment, storage, or disposal facility (TSDF). Note: Depending on how a waste or its constituents are recycled and/or treated, more than one treatment/disposal category may apply. All applicable boxes in column 2 of the waste inventory table should be checked. UN -012 - 2/18 http://www.unidoes.org Rev. 05/31/00