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UNIFIED PROGR4MCONSOLIDATEDFORM <br />HA7-4RDOUS WASTE <br />REMOTE WASTE CONSOLIDATION SITE ANNUAL NOTIFICATION <br />Pigof <br />—of <br />720 <br />❑ a. Initial ❑ b. Revised ❑ c. Arrlual <br />I. GENERAL INFORMATION <br />BUSINESS NAME (&meuFACTLITYNAMEorDBA -Doing Business As) 3 FACILITYIDII 1 - <br />IL CONSOLIDATION SITE INFORMATION <br />ADDRESS <br />FACILITY EPA M# 2 <br />CITY 722 <br />CA 2IP CODE 723 <br />DESCRIPTION OF THE TYPE(S) OF REMOTE LOCATION(S) AND SOURCE(S) FROM WHICH THE NON-RCRA HAZARDOUS WASTE WILL BE COLLECTED (ie. 724 <br />power pole) <br />725 <br />DESCRIPTION OF THE TYPE OF HAZARDOUS WASTE THAT MAY BE COLLECTED <br />n ste? <br />Do you treat your hazardous waste at the consolidation <br />727 <br />VOLUME CONSOLIDATED <br />UNITS ❑ a. Pounds ❑ b. Gallons I <br />(op Eno ❑ Yes ❑ No <br />III. BASIS FOR NOT NEEDING A FEDERAL PERMIT <br />(QKk atltbat apply) 729 <br />❑ a. The hazardous waste being consolidated is not hazardous waste under federal law aLhoughthe waste is regulated as hazardous waste under <br />California state law. <br />❑ b The lia_zardous waste is hazardous waste under federal law, but tram portation to and accumulation at the cons olidatim site of the waste is not <br />subject to permitting requirements under federallaw for the following other reason(s): <br />IV. CERTIFICATIONS <br />I certifyunder penalty oflaw that the activities described in these documents meetthe applicable eligibility and operating requirements ofstate statutes and regulations <br />for remote waste and consolidation sites. I finrther 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 personmelproperly gather and evaluate the information submitted. Based on 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 of nyknowledge and belie£ true, accurate, and complete. I am <br />aware that there are substantialpenalties for submitting false information, including the possibility offne sand imprs ormment for knowing violations. <br />SIGNATURE OWNER/OPERATOR <br />730 <br />DATE <br />NAME OF OWNER/OPERATOR (Print) 731 <br />TITLE OF OWNER/OPERATOR 732 <br />rrnr+ .. is � Inn _..___....n\ - ^'T r.-.Y...,__L.r mai, i inc <br />