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10x'29/2008 01:22 2093691668 CENTRAL VALLEY WASTE PAGE 02 0 • HAZARDOUS WASTE TANK SYSTEM WRITTEN AS ESSMENT TEMPORARY EXEMPTION APPLICATIO For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited, 74/e 22 California Code of Regulations (CCR). Section 66265.192(j) California hazardous waste regulations require that a hazardous waste tank system onsite hazardous waste treatment facility have a written assessment certified by P operatedProfessional al eng nor (P ) p generator or placed in service. The owner/operator of an aboveground tank y e (PE) prior r- being hazardous waste may apply to the local Certified Unified Pro stem that is either or an exxe si or holds non-RCRA y pp y gram Agency (CUPA) for an extensi of up to 36 months to the deadline for submittal of the written assessment. This form must be used to apply for su an extension. You should first review the Unidocs document titled "Hazardous Waste Tank System Requiremen for Large Quantity Generators and Onsite Treatment Facilities." That document and CUPA/local HazMat agency ju sdiotion and contact information are available at www.unidocs.org. Complete a separate form for each tank system. I the local CUPA and Fire Marshal authority are not the same agency, you must first obtain sip -Off from the Fire Marshal pr his/her authorized representative in Section 7, below, then forward the application to the CUPA, I. Facility Name (Tank Site): Central Vali@ Wast@ S@rviaes EPA ID No.: CAL000194471 Address: 1333 E. Turner Road city: Lodi z : 95240 2. What is the tank volume in gallons? — 1000 gallons 3. What type of waste does this tank hold? ® Used oil; ❑ Used Antifreeze; [] Other (Specify): 4. Does this tank system have secondary containment capable of containing 100% of the contents of the to and ancilla pipin volume? ® Yea; ❑ No. rY P P g 5. Is this tanks tem I system exposed to precipitation? ❑Yea; ®No. If "Yes," does the secondary containment' ystem have sufficient capacity, in addition to that required above, to contain infiltration from a 25 -year, 24-hour rainfall event?Yes; ElNo. 6, Is the tank system secondary containment provided with a leak detection system designed and operated so tit will delict either the failure of the primary and secondary containment structure or any release of hazardous waste or acc ulated liquid in the secondary containment system within 24 hours? ® Yes; ❑ No. 7. FIRE MARSHAL, APPROVAL: Our agency has approved the design and installation of this tank sys Fire Marshal or Representative's Name (Print) Fire Marshal or Representative's Signature Datc APPLICANT CERTIFICATION: I have read the Undoes "Hazardous Waste Tank System Requiremenfor Large Quantity Generators and Onsite Treatment Facilities," I certify that the tank system for which this exemption is ing requested is an aboveground tank (i.e., 90% or more of the total system volume is above -grade) and the tank system Is,i �they RCRA-exempt or the waste it holds is a non-RCRA hazardous waste. I have attached a drawing of the layout of t� tank facility (e.g., Hazardous Materials Business Plan Site Plan/Storage Map) with the location of this tank and any a aciated piping runs (other than vent lines and vertical fill tubes) clearly Identified. I declare that the above Information is cox ect to the best of my knowledge. I agree to comply with all applicable state laws and regulations relating to the operation and management of this tank system. I represent the: ❑ Tank Owner; M Tank Operator Brian Waters (District Manager) �&=11/19/2008 Exemption Requester's Name (Print) Exemption Requester's Signaturc Date Address: 1333 E. Tumor Road City: Lodi IZip 95240 Phone No.: (209) 333-5611 Fax No.: (209) 369-8894 entail: bwaters@wm.com This bax Is for CUPA use only THIS REQUEST FOR EXEMPTION IS: ❑ Denied; ❑ Granted. Approval constitutes an exemption for the bat k system described above pursuant to Title 22 CCR §66265.1926) for a period of _ months from the date of approval. CUPA: Date: Print Name: _ Sign Name: UN -071-F �' voo 199