Laserfiche WebLink
Stat_Apf California-California Environme Aotection Agency artment of Toxic Substances Control <br /> 46 UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION -.FACILITY PAGE <br /> Pae of <br /> BUSINESS NAME(Same as FACILITY NAME or DBA Doing Business As) s FACILITY ID# 1 <br /> 0 0 1 J 15- <br /> II. STATUS <br /> NOTIFICATION STATUS 600IT STATUS(Check all that apply) 601 <br /> [:] ;raMFacility <br /> a Amended Permit ❑d Variance <br /> jfb Initial ❑b Interim Status ❑e Consent Agreement <br /> ❑c Renewal(PBR Only) ❑c Standardized Permit <br /> III. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of units you operate in each tier,attach one unit notification page for each unit except CE-CL) <br /> 602 <br /> A Conditionally Exempt—Small Quantity Treatment(CESQT)(May not function under any other tier) <br /> B Conditionally Exempt Specified Wastestream(CESW) <br /> C Conditionally Authorized(CA) <br /> D Permit by Rule(PBR) <br /> E Conditionally Exempt—Limited(CEL) <br /> F Conditionally Exempt Commercial Laundry(CE-CL) (No unit page is required for laundries) <br /> G TOTAL UNITS(Must equal the number of unit notification pages attached plus the number of CE-CL units) <br /> IV. CERTIFICATION AND SIGNATURE <br /> Waste Minimization 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 <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment. <br /> Tiered Permitting Certification I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and secondary containment requirements. I certify under penalty of law that this document and all <br /> attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the <br /> information submitted. Based on my inquiry of the person or persons who manage the system,or those directly responsible for gathering the information,the <br /> information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> I am aware that there are substantial penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> SIGNATU OF ER/OP TOR DATE tiO3 <br /> 67. Ai- 6 C Zoo <br /> NAME OF OWNER/OPERATOR 604 TITLE OF OWNER/OPERATOR 605 <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes inNo <br /> State Reason for Request <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)must submit: PBR ONLY <br /> ❑ 1 One unit specific notification page and one treatment process page per unit ❑ 1 Tank and container certifications,if required <br /> ❑ 2 Plot Plan(or other grid/map) ❑ 2 Notification of local agency or agencies <br /> ❑ 3 Notification of property owner,if different from business owner <br /> PBR&CA ONLY: <br /> ❑ 1 Closure Financial Assurance(formerly DTSC form 1232) <br /> ❑ Self Certified(<$10,000) ❑ Other mechanism <br /> ❑ 2 Prior Enforcement History,if applicable <br /> UPCF(12/99 revised) 20 Formerly DTS 177 <br />