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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION <br /> I. FACILITY INFORMATION <br /> FA ILITY NAME: \^ ,fir• EPA I(D'�NiUMBER: <br /> h0fik Q&jxko)l <br /> v� .' <br /> LO �N/j AILING ADDRES F�ACILI/fTY PHONE NO: <br /> `- <br /> CITY: ZIP CODE: <br /> FtIT,Y CONTACT NAME: CONTACT PHONE NO: <br /> II. PROCESS DESCRIPTION <br /> TYPE OF AEROSOL CANS: <br /> ESTIMATED VOLUMES OR QUANTITIES TO BE PROCESSED MONTHLY: <br /> 15 -a'-�_s <br /> TREATMENT PROCESS OR PROCESSES DESCRIPTION: <br /> EQUIPMENT DESCRIPTION: <br /> t' -J <br /> &M5�� L�11 r1 <br /> EQUIPMENT DESIGN CAPACITIES: <br /> III. HAZARDOUS WASTE TREATMENT RESIDUALS <br /> DESCRIPTION OF THE CHARACTERISTICS OF HAZARDOUS TREATMENT RESIDUALS: <br /> DESCRIPTION OF MANAGEMENT OF ANY HAZARDOUS TREATMENT RESIDUALS: <br /> f <br /> IV. CERTIFICATION <br /> I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system <br /> designed to assure that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of the person or persons <br /> who manage the system,or those persons directly responsible for gathering the information,the information submitted is,to be the best of my <br /> knowledge and belief,true,accurate,and complete.I am aware that there are significant penalties for submitting false information,including the <br /> possibility of fine and im risonme for knowing violations. <br /> SIGNATURE*: DATE: <br /> 7Zl6 Z6 <br /> NAME OF PERSO:rCPVZP?-Z__.ING CERTIFICATION(PRINT): TITLE: <br /> � . <br /> *Note:Per the CA Code of Regulations,Title 22,section 66270.11,this notification must be signed as follows: <br /> • For a corporation: by a responsible corporate officer,e.g. president,secretary,treasurer,or vice-president of the corporation in charge of a <br /> principal business function,or any other person authorized to perform similar policy or decision-making functions,which govern the operation <br /> of the regulated facility,for the corporation. <br /> • For a partnership or sole proprietorship:by a general partner or the proprietor,respectively <br /> • For a municipality,State,Federal,or other public agency:by either a principal executive officer or ranking elected official. For purposes of this <br /> section,a principal executive officer of a Federal agency includes:the chief executive officer of the agency,or a senior executive officer having <br /> responsibility for the overall operations of a principal geographic unit of the agency(e.g.,Regional Administrators of USEPA). <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />