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EPA ID NUMBER CAD 573193 Page 3 of CZ VI. ATTACHYW.NTS: I. A plot plan!map detailing the location(s) of the covered unit(s) in relattoo to the facility boundaries. © 2. A unit specific notification form for each unit to be covered at this location. VII. CFRTIFICATIONS: This form must be signed by an authorized corporate officer or any other person in the company who has operational control and performs decision-malting functions that govern operation of thefacility(per title 22, California Code of Regulations (CCR) section 66270.11). AU three copier must have orfglrral signmtwzr. Wasto Minirnimtion 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 economically practicable and that I have selected the practicable method of trcatarent, storage, or disposal currently available to me which minimizes the present and future threat to human health and the environment. tiered Permitting Certification I certify that the unit or un is described in these documents meet the eligibility and operating requirements of state statutes and regulations for the indicated permitting tier, including generator and secondary containment requirements. i understand that if any of the units operate under Permit by Rule or Cooditirmal Authorization, I will also be required to provide required financial assurances by January 1, 1994, and conduct a Phase I environmental uussment by January 1, 1995. 1 certify undn penalty of law that this document and all attachments were prepared under my direction or supervision in assonance with a system designed to assure that qualified personnel properly gather and evahrate the information submitted. Based on my inquiry of the portion or persons who manage the system, or those directly responsible for gathering the information, the information is, to the bast of my knowledge and belief, true, accurate, and complete. I am aware that thele are substantial penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. J. P. R_Qgers factory Man r Name (Print or Type) Title Signature Date Signed OPERATING REQUIREMENTS: Please note that generators treating hazardous waste onsite are required to comply with a number of operating requirements which differ depending on the rier(s) under which one operates. These operating requiremens are set forrh in the matures and rrgulateocu, some of which are referenced in the 71er-Specifrc Facrshres. SUBNUSSION PROCEDURES: You mart z�+s two coyish of this completed notifictuion by eerrifred mail, return receipt requerred, to: Department of Toxic Substances Control Form 1772 Orsire Hazardous Waste P-atmenr Unit 400 P Street, 4th Floor (walk in only) P.O. Box 806 Sacramento, CA 95812-0806. You must alio aubmu�o e�of the notification and attachments to the local regulatory agency in your jurudiawn as listed in the instruction materials. You must also retain a copy as part of your operating record. AU three forme must hart original signatures, nor photocopies. DTSC 1772 (1193) Page 3 C'S'd ZH13H*f-H ZT :60 E6, 0E 6HW