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M <br />J <br />State of California - Califomia Environmental Protection Agency D f T <br />epartment o oxlc Substances Control <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION <br />- FACILITY PAGE <br />s ACI 1 I � <br />BU$IN $$ AME(Sameu FACLLITY NAxfE or DBA Daiy Businm NPace of"al <br />t2 ew fon ec7� CGtI I <br />II. STATUS <br />NOTIFICATION STATUS aoo PER,WT STATUS (Check all thaz apply) eoi <br />❑ a Amended e792 Facility Permit ❑ d Variance <br />❑ b Initial ❑ b Interim Status ❑ e Consent Agreement <br />CKc Renewal (PBR Only) ❑ c Standardized Permit <br />III. NUMBER OF UNITS AT FACILITY <br />(Indicate the number of units you operate in each tier, anach 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) w: <br />B Conditionally Exempt Specified Wastestream (CESW) <br />C 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 number of CE -CL units) <br />IV. CERTIFICATION AND SIGNATURE <br />Wade Minimization I ccrtih 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 1 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 Permirine 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 pmpatcd 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 />1 am aware that there arc substantial penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. <br />SIGNA U SNE <br />K�/Jf�c• <br />.. L) <br />.',A.%Ej Ow'NEIUOPERATOR <br />TITLE OF OWNER/OPERATOR ws <br />REQUEST FOR SHORTENED REVIEW PERIOD (CE and CA only) ❑ Yes ❑ No <br />State Reason for Request <br />i <br />V. ATTACHMENTS (Check if attached) <br />.ALL tiers except CELL (Laundries) must submit. <br />PBR ONLY <br />❑ I One unit specific notification page and one trcaenent process page per unit <br />❑ 1 Tank and container certifications, if required <br />❑ '- Plot Plan (or other gridlmap) <br />❑ 2 Notification of local agency or agencies <br />❑ 3 Notification of propem owner, if different from business owner <br />PBR ah CA ONLY <br />❑ 1 Closure Financial Assurance (formerly DTSC forth 12322) <br />❑ SclfCertifted(<SI0.000) ❑ Other mechanism <br />0 2 Prior Enforcement History, if applicable <br />