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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 EAST HAZELTON AVENUE, STOCKTON, CA 95205 <br /> (209) 468-3420 FAX (209) 468-0138 <br /> UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION <br /> This notification shall be submitted in person or by certified mall,with return receipt requested <br /> L FACILITY INFORMATION <br /> FAG MEt E A ID NUMBER: ( / <br /> LOCATIONIMAILING ADDRESS: FACILITY PHODIIE NO: <br /> 232.4 ►Z- - 3 . 0 <br /> CITY: ZIP CODE: ^2 <br /> �T� { Y <br /> FACILITY CONTACT NAME: CONTACT PHONE NO: <br /> P_r7T�>vr� M- ( 7 -33/8 <br /> II. PROCESS DESCRIPTION <br /> TYPE OF:AEROSOL CANS; <br /> ESTIMATED VOLUMOR UANTITIES 84 PROCESS D MONTHLY: <br /> TREATMENT PROCESS OR PROCESSES DESCRIPTION: <br /> EQUIPMENT DESCRIPTION: <br /> Is_ " w1 <br /> EQUIPMENT DESIGN CAPACITIES: <br /> III. HAZARDOUS WASTE TREATMENT RESIDUALS <br /> DESCRIPTION OF THE CHARACTERISTICS OF HAZARDOUS TREATMENT RESIDUALS: <br /> 11� p1e 1-4Q <br /> DESCRIPTION OF MANAGEMENT OF ANY HAZARDOUS TREATMENT RESIDUALS: <br /> IV. CERTIFICATION <br /> I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system <br /> designed to assure that qualified personnel properly gather and evaluate the Information submitted.Based on my inquiry of the person or persons who <br /> manage the system,or those persons directly responsible for gathering the information,the Information submitted Is,to be the best of my knowledge and <br /> belief,true, accurate,and complete. I am aware that there are significant penalties for submitting false information,including the possibility of fine and <br /> Imprisonment r knowing violations.. <br /> SIGNATURES DATE: <br /> _ // _ �3 <br /> NAME OF PERSON SIGNING IFICATION(PRINT): TITLE: <br /> ©L.4i-4— /'vt✓�n�AG�Cdt <br /> "Note:Per the CA Code of Regulations,Title 22,section 66270.11,this notification must be a gned as follows: <br /> • For a corporation: by a responsible corporate officer,e.g.president,secretary,treasurer,or vice-president of the corporation in charge of a principal <br /> business function,or any other person authorized to perform similar policy or decision-making functions,which govern the operation of the regulated <br /> facility,for the corporation. <br /> • For a partnership or sole proprietorship:by a general partner or the proprietor,respectively <br /> • For a municipality, State. Federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this <br /> section, a principal executive officer of a Federal agency Includes: the chief executive officer of the agency, or a senior executive officer having <br /> responsibility for the overall operations of a principal peographic unit of thea en e. .,Regional Administrators of USEPA. <br />