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0 Onsite Hazardous Waste Treatment Notification—Facility Form Instructions (Formerly DTSC Form 1772) Complete this form if your facility performs onsite treatment of hazardous waste(s)generated onsite and the facility is eligible under the Conditional Exemption(CE),Conditional Authorization(CA),or Fixed Treatment Unit(FTU)Permit by Rule(PBR)tiers. Submit one Onsite Hazardous Waste Treatment Notification- Facility page per facility, regardless of the number of treatment units located at the site. Attach separate Onsite Hazardous Waste Treatment Notification - Unit and Waste and Treatment Process Combinations pages for each treatment unit at the facility. Please number all pages of your submittal. (Note: Numbering of these instructions follows the UPCF data element numbers on the form.) 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Facility Name. 600. NOTIFICATION STATUS -Check whether this notification is your initial notification under the Tiered Permitting system; an amended notification;or,for PBR only,a renewal notification. 601. PERMIT STATUS-If this facility has a state-issued hazardous waste permit or grant of authorization,check the appropriate box to indicate the permit status. 602. NUMBER OF UNITS-Enter the number of units you operate at this facility in each permit tier or category. SIGNATURE OF OWNER/OPERATOR-The business owner,or officer of the company who is authorized to make decisions for the facility and who has operational control, shall sign in the space provided. In most companies, this is not the environmental compliance or technical staff. Original signatures are required. 603. DATE CERTIFIED-Enter the date the form was signed. 604. OWNER/OPERATOR NAME-Print or type the full name of the person signing the page. 605. OWNER/OPERATOR TITLE-Enter the title of the person signing the page. REQUEST FOR SHORTENED REVIEW PERIOD - Generators operating under the PBR tier are not authorized until they are notified by their Certified Unified Program Agency(CUPA). Generators operating under CA and CE are legally authorized 60 days after submitting a complete notification. The time period between notification and authorization may be shortened if the owner or operator shows good cause. Check the appropriate box to indicate whether or not you are requesting to be authorized sooner than the standard 60-day period. If you check"Yes," state the reason(s) for your request (attach additional sheets if needed). Authorization will be automatically effective on the date the completed notification is received by your CUPA. ATTACHMENTS -Check the appropriate boxes to indicate that all required document submittals are attached to this form. (Note: Commercial Laundries are not required to provide attachments.) ALL FACILITIES: 1. Complete an Onsite Hazardous Waste Treatment Notification - Unit form and Waste and a Treatment Process Combinations form for each unit covered by this notification. 2. Provide a plot plan or map detailing the location(s) of the unit(s) at this facility. Clearly indicate the facility boundaries and major features. The Storage Map prepared for your Hazardous Materials Business Plan may be used as long as the unit numbers for the units covered by this notification are shown. PBR and CA ONLY:* 1. Complete and attach the Certification of Financial Assurance for Closure(UPCF form HWF 1232). Check the appropriate box to indicate whether you have Self-Certified(closure costs must be less than$10,000)or are submitting a financial mechanism. 2. Prior Enforcement History information is required only if your facility was the subject of any convictions, judgments, settlements or final orders resulting-from an action by any local, state, or federal environmental, hazardous waste, or public health enforcement agency. If applicable,attach a statement or summary that lists the cases for the last three years and provide a copy of the cover sheet from each document (conviction, settlement, etc.). The summary should include case and docket number, name and address of the agency, date, brief explanation, type of case (criminal, civil, administrative) and final resolution(including fines and penalties). PBR ONLY: 1. 22 CCR§67450.2(b)(3)(G)requires that tank and/or containment system certifications be submitted,when applicable. Specific standards are in 22 CCR§66264.175(c)(containers)and 22 CCR§66265.191(a)and 66265.192(a)(tanks). 2. Notification of local agencies. Attach documentation of the other local agencies notified of your operation.(e.g.sewer agency). 3. Notification of property owner. If the property owner is different than the operator, provide documentation that the facility operator has notified the property owner of the operation of this hazardous waste treatment unit under PBR. * For PBR and CA,a Phase I environmental assessment must be submitted to DTSC,not to your CUPA. The assessment checklist and instructions are available from DTSC. Call(916)324-2423 or write to the DTSC-Unified Program Section at 400 P Street,4th Floor,P.O.Box 806,Sacramento,CA 95182-0806. Completed Phase I assessments should be submitted to the same address. UPCF hwf1772f(1/99)-2/2 http://www.unidocs.org Rev.02/16/00