Laserfiche WebLink
*ewe -..I <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> E <br /> TE HAZARDOUS WASTE TREATMENT NOTIFICATION- FACILITY PAGE <br /> Page !- of 1 <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(same ac F'ACttrry\.vM U or DBA-Doing Business As) FACILITY IDk <br /> Central Spring, Inc. I I � I � LLEII= ­1 <br /> U. STATUS <br /> NOTIFICATION STATUS 000, PERMIT STATUS(Check all that apply) °cf <br /> ❑a. Amended ❑a. Facility Permit ❑d. Variance <br /> ®b. Initial ❑b. Interim Status ❑e. Consent Agreement <br /> ❑c. Renewal(PBR Only) ❑c. Standardized Permit <br /> III. NUMSER OF UNITS AT FACILITY <br /> (Indicate the number of units you operate in each tier. Attach one unit notification page for each unit except CE-CL) <br /> A- Conditionally Exempt-Small Quantity Treatment(CESQT)(May not function under any other tier.) hoz' <br /> B. Conditionally Exempt Specified Wastestream(CESW) <br /> C. 1 Conditionally Authorized(CA) <br /> D. Permit by Rule(PBR) <br /> E. Conditionally Exempt-Limited(CEL) <br /> F. Conditionally Exempt Commercial Laundry(CE-CL) (No unit page is required for laundries.) <br /> G. TOTAL UNITS(Must equal the number of unit notification pages attached plus the numberof CE-CL units.) <br /> N. CERTIFICATION AND SIGNATURE <br /> Waste Minimization-I certify that I have a program in place to reduce the volume,quantity and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment. <br /> Tiered Permitting Certification- I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and secondary containment requirements. I certify under penalty of law that this document and all <br /> attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the <br /> information submitted. Based on my inquiry of the person or persons who manage the system,or those directly responsible for gathering the information, the <br /> information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> I am aware that there are substantial penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> SI(3NATLIRE OF OWNPMVERATOR DATE (A3 <br /> :T dA44 6W <br /> 6i 3�/zvv <br /> NAME OF OWNERIOPERATOR etw. TiTLE OF OWNER/OPERATOR 605 <br /> Tatsuo Tshida President / CEO <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes ® No <br /> State Reason for Request: <br /> V.ATTACHMENTS(Check if attached) <br /> ALL liets except CE-CL(Laundries)must submit: PBR ONLY <br /> ® 1, One unit specific notification page and one treatment process page per unit ❑ I. Tank and container certifications,if required <br /> ER 2. Plot Plan(or other grid/map) ❑2. Notification of local agency or agencies <br /> [13. Notification of property owner,ifdiffetent from business owner <br /> PBR&CA ONLY: <br /> I. Closure Financial Assurance(formerly DTSC form 1232) <br /> 10 Self Certified(<Si 0,000) ❑ Other mechanism <br /> 2. Prior Enforcement History,ifapplicable <br /> U PCF hw f1777f(1199)-I12 www.unidocs.org Rev.02/16/00 <br />