BILLING - Laserfiche WebLink

Home Browse Search

p,t e Ce� • �� fir d '�'*7 Cel"d o n¢ !-o P7sC- State of California-California Environritt.—Aal Protection A enc Department of Toxic Substances Control UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS WASTE ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION — FACILITY PAGE Pae of BUS ar FACILITY NAME or DBA Doing Business As) 3 FACILITY ID# H. STATUS NOTIFICATION STATUS 600 PERMIT STATUS(Check all that apply) 601 ❑a Amended Era Facility Permit ❑d Variance Erb Initial ❑b Interim Status ❑e Consent Agreement ❑c Renewal(PBR Only) ❑c Standardized Permit HI. NUMBER OF UNITS AT FACILITY (Indicate the number of wits you operate in each tier,attach one unit notification page for each wit except CE-CL) 602 � A Conditionally Exempt-Small Quantity Treatment(CESQT)(May not function under any other tier) , B Conditionally Exempt Specified Wastestream(CESW) C Conditionally Authorized(CA) D Permit by Rule(PBR) E Conditionally Exempt-Limited(CEL) F Conditionally Exempt Commercial Laundry(CE-CL) (No unit page is required for laundries) G TOTAL UNITS(Must equal the number of unit notification pages attached plus the number of CE-CL units) IV. CERTIFICATION AND SIGNATURE Waste Minimization I certify that 1 have a program in place to reduce the volume,quantity and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and the environment. Tiered Permitting Certification I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and regulations for the indicated permitting tier,including generator and secondary containment requirements. I 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 personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system,or those directly responsible for gathering the information,the information is,to the best of my knowledge and belief,true,accurate,and complete. 1 am aware that there are substantial penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. SIGNATURE OF OWNER/OPERATOR DATE 603 NAME OF OWNER/OPERATOR 6W4 TITLE OF OWNER/OPERATOR 605 REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes ❑ No State Reason for Request V.ATTACHMENTS(Check if attached) ALL tiers except CELL(Laundries)must submit: PBR ONLY ❑ 1 One unit specific notification page and one treatment process page per unit ❑ I Tank and container certifications,if required ❑ 2 Plot Plan(or other grid/msp) ❑ 2 Notification of local agency or agencies ❑ 3 Notification of property owner,if different from business owner PBR&CA ONLY: ❑ I Closure Financial Assurance(formerly DTSC form 1232) ❑ Self Certified(<$10,000) ❑ Other mechanism ❑ 2 Prior Enforcement History,if applicable UPCF(12/99 revised) 20 Formerly DTSC 1772