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UNIFIED PROGRAM CONSOLIDATED FORM <br />H 4ZARD OU S W AST E <br />REMOTE WASTE CONSOLIDATION SITE ANNUAL NOTIFICATION <br />Pag of <br />720 <br />❑ a. Initial ❑ b. Revised ❑ c. Arnual ---- <br />--I. <br />1. GENERAL INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Dadng Budnen Ai) 3 <br />FACILITY III <br />l <br />II. CONSOLIDATION SITE INFORMATION <br />ADDRESS <br />2 <br />FACILITY EPA ID# <br />CITY 722 <br />CA ZIP CODE 723 <br />DESCRIPTION OF THE TYPE(S) OF REMOTE LOCATIONS) AND SOURCE(S) FROM WHICH THE NON-RCRA HAZARDOUS WASTE WILL BE COLLECTED (ie. 724 <br />powerpole) <br />725 <br />DESCRIPTION OF THE TYPE OF HAZARDOUS WASTE THAT MAY BE COLLECTED <br />Do you treat your hazardous waste at the consolidation s ie? 725 <br />ESTIMATED MONTHLY 727 <br />VOLUME CONSOLIDATED <br />UNITS Cl a. Pounds ❑ b. Gallons 728 <br />(opiomv El Yes ❑ No <br />IIL BASIS FOR NOT NEEDING A FEDERAL PERMIT <br />729 <br />(Check alltintappM <br />❑ a. The hazardous waste being consolidated is not hazardous waste under federal law although the waste is regulated as hazardous waste under <br />California state law. <br />❑ b. The hazardous waste is hazardous waste under federallaw, but transportation to and accunulation at the consolidation site ofthe waste is not <br />subject to permitting requirements under federallaw for the following other reason(s): <br />IV. CERTIFICATIONS <br />I certify under penalty oflaw that the activities described in these documents me et the applicable eligibility and operating requirements of state statutes and regulations <br />for remote waste and consolidation sites. I further certify that this document and all attachments were prepared under my direction or supervision in accordance with a <br />system designed to assure that qualifie d personnelproperly gather and evahate the informnation submitted. Based m my inquiry ofthe person or persons who manage <br />the system, or those directly responsible for gathering the information, the information is, to the best ofmyknowledge and belief true, accurate, and complete. I am <br />aware that there are substantialpenakies for submitting false inforrnatiort, including the poss:b Uy offines, and imprisonment for knowing violations. <br />730 <br />SIGNATURE OWNER/OPERATOR <br />DATE <br />NAME OF OWNER/OPERATOR (Prit) 731 <br />TITLE OF OWNER/OPERATOR 732 <br />TTT r'TJ /1 � Inn -____- A\ 1�^f r. -.—.._i. � n 1 1 n <br />