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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE , STOCKTON , CA 95205 (209) 46 &3420 FAX (209) 46&0138 UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION This notification shall be submitted in person or by certified mail, with return receipt requested I . FACILITY INFORMATION FACILITY NAME: EPA ID NUMBER: clan CAejYCki s LAL000 a d L LOCATION/MAILING ADDRESS: FACILITY PHONE NO: T�rss 1 � � l_c�, doh (efz / C4 l CITY: 'n ZIP CODE: / Z6C� IL-LO � � G L( FACT ITY CONTACT NAME. CONTACT PHONE NO: II . PROCESS DESCRIPTION TYPE OF AEROSOL CANS: ESTIMATED VOLUMES OR QUANTITIES TO BE PROCESSED MONTHLY: ao TREATMENT PROCESS OR PROCESSES DESCRIPTION: EQUIPMENT DESCRIPTION: I o 4r' of S19,64 I h . i�P,Y' OSa 1 v w�T3t a-I o I -I-w- . G ��,r �vi � EQUIPMENT DESIGN CAPACITIES: l0 6ld 5 l h ar w44 iVVl V� AA c � ✓ d�61A s s C. . 196 HAZARDOUS WASTE TREAT NT RESIDUALS DESCRIPTION OF THE CHARACTERISTICS OF HAZARDOUS TREATMENT RESIDUALS: 1A � 01 . DESCRIPTION OF MANAGEMENT OF ANY HAZARDOUS TREATMENT RESIDUALS: �Q (� Si � GcS �LR '(� G✓ � � '� • IV. CERTIFICATION 1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified pers nnel properly gather and evaluate the information submitted . Based on my inquiry of the person or persons who manage the system, or those p rsons irectl responsible for gathering the information, the information submitted is, to be the best of my knowledge and belief, true, accurate, and co tete. am are that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowingvio ins. SIGNATURE': DATE. NAME OFIWIML SON SIGNI CE TIFICATIO (PRINT) : TITLE: itau� LeA 'Note: Pert a CA Code of Regulations, Title 22, section 66270.11 , this notification must be signed as follows: For a corporation: by a responsible Corporate officer, e.g, president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person authorized to perform similar policy or decision-making functions, which govern the operation of the regulated facility, for the corporation . . For a partnership or sole proprietorship: by a general partner or the proprietor, respectively For a municipality, State, Federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this section, a principal executive officer of a Federal agency includes: the chief executive officer of the agency, or a senior executive officer having responsibility for the overall operations of a principal geographic unit of thea enc e. . , Regional Administrators of USEPA .