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State of California — California Environmental Protection Agency Department of Toxic Substances Control <br />A. ❑ Removes discrete components typically removed during the normal operation of the OWED <br />(batteries, ink cartridge, etc.) and the handler conducts the disassembly in a manner prescribed <br />in the operating manual for the device. [Note: If this is the only treatment you perform, do not <br />fill out this from. Please use Form 1382 instead.] <br />B. ❑ Dismantling UWEDS into only their respective components using: <br />❑ <br />Manual methods and hand tools or mechanical separation of parts only. <br />❑ <br />Other please specify <br />❑ <br />Treatment residuals are components of the electronic device (e.g., circuit boards, <br />integrated circuits, metals, plastic, wiring, universal waste batteries and lamps, etc.) <br />C. ❑ Processing (without heat, chemicals or water) <br />❑ <br />Shred or cut, etc., whole or parts of UWED after removing batteries, lamps, and other <br />universal wastes. <br />❑ <br />Components of UWEDs are processed after removal (e.g., circuit boards, chips, other <br />components). <br />❑ <br />Resultant materials generated from treatment are scrap metal and universal waste <br />batteries and lamps. <br />D. ❑ Processing (without heat, chemicals or water) <br />❑ Size reduction, crushing, cutting, sawing, compacting, shredding <br />❑ Separation technology <br />❑ Other please specify <br />❑ Treatment residuals exhibit a hazardous waste characteristic and do not meet the <br />definition of scrap metal or do not qualify for management as universal waste. <br />E. All of the following documents are required if you have checked "D" above. <br />❑ I have attached documentation estimating the cost of facility closure prepared pursuant to title <br />22, California Code of Regulations, section 66265.142. <br />❑ I have attached documentation demonstrating financial assurance for closure pursuant to title <br />22, California Code of Regulations, section 66265.143. <br />❑ I have attached documentation demonstrating financial responsibility for liability pursuant to title <br />22, California Code of Regulations, section 66265.147. <br />G. Property Owner Notification [22 CCR sections 66273.13/.33(d)(3)(F)(1)(a)(6) and 66273.83(c)(2)(A)(2)(e) or <br />66273.83(d)(1)(A)(2)(e)]. <br />❑ I have attached documentation demonstrating that I, the CRT material handler and/or UWED handler, has notified <br />the property owner (if different from the handler) that I am conducting hazardous waste treatment and recycling <br />operation(s) at the facility pursuant title 22, California Code of Regulations, division 4.5, chapter 23 (Universal Waste <br />Regulations). <br />❑ I, the CRT material handler and/or UWED handler, am the property owner of the facility specified in Section "A". <br />H. Inspection <br />❑ I, the CRT material handler and/or UWED handler, am aware that the facility specified in Section "A" is subject to <br />unannounced inspections by state or local agencies to verify compliance with applicable universal waste regulations, air <br />laws, worker health and safety laws, local zoning requirements and seismic and precipitation design standard <br />requirements. <br />DTSC 1388 (11/15/04) Page 4 of 5 <br />