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State of California-California Environmental Protection Agency Department of Toxic Substances Control <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION- FACILITY PAGE <br /> Pae of <br /> BUSINESS NAME(s as FACMIrY NAS or DBA noir,aari�M) ; FACB.ITYIDN 1 <br /> 5U141 A) 4ho P CORP• <br /> II. STATUS <br /> NOTIFICATION STATUS foo PERMIT STATUS(Check all that apply) fol <br /> ❑a Amended ❑a Facility Permit ❑d Variance <br /> ❑b Initial ❑b Interim Status ❑e Consent Agreement <br /> [kc Renewal(PBR Only) ❑c Standardized Permit <br /> III. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of units you operate in each tier,attach one unit notification page for each unit except C&CL) <br /> A Conditionally Exempt—Small Quantity Treatment(CESQT)(May not function under any other tier) fol <br /> B Conditionally Exempt Specified Wastestream(CESW) <br /> C Conditionally Authorized(CA) <br /> Permit by Rule(PBR) <br /> E Conditionally Exempt—Limited(CEL) <br /> F Conditionally Exempt Commercial Laundry(CELL) (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 /> W. 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 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 Permitting Certification I certify that the unit or units described in these documents meet the eligibility and operating requirements of state mutates 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 /> SIGNATURE OF OWNER/OeURAXOR DATE 603 <br /> NAME <br /> ,QF OWNER/OPE T foes TITUgqF OWNER/OPERATOR fos <br /> lI51 I Lya-).,r MAMQ&VA, <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes 9f No <br /> State Reason for Request <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)most submit: PBR ONLY <br /> X,I One unit specific notification page and one treatment process page per unit X 1 Tank and container certifications,if required <br /> A2 Plot Plan(or other grid/map) CK2 Notification of local agency or agencies <br /> ❑ 3 Notification of property owner,ifdifferent from business owner <br /> PBR&CA ONLY: <br /> I Closure Financial Assurance(Formerly DTSC form 1232) <br /> ❑ SCIfCemfied(<$10,000)A Other mechanism <br /> ❑ 2 Prior Enforcement History,if applicable <br /> UPCF(12/99 revised) 20 Formerly DTSC 1772 <br />