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State of California-California Envirort._�ttal Protection Agency �,/ Department of Toxic Substances Control
<br /> Onsite Hazardous Waste Treatment Notification — Facility
<br /> There are several treatment activities that,although they would be otherwise regulated,are exempt under the law provided certain conditions are met.
<br /> Exempt treatment activities are described in Appendix A of these instructions(see below)and if your treatment activities are exempt then no notification
<br /> is required for these activities.
<br /> If your treatment activities do not qualify for an exemption complete this page if your facility is a hazardous waste generator performing treatment of
<br /> hazardous wastes at the site where the waste is generated,and the facility is eligible under the Conditional Exemption(CE),or Conditional Authorization
<br /> (CA)tiers,or operates a Fixed Treatment Unit(FTU)under the Permit by Rule(PBR)tier. To determine which tier or tiers apply to your operations,refer
<br /> E�Lr to the DTSC Onsite Tiered Permitting Flow Chart,which graphically displays the eligible waste streams and treatment processes by tier.
<br /> Submi one acili a e ns a azar ou Waste Treatment Notification-Facili er facility,regardless of the number of treatment units located at the
<br /> site-.-A—tta-cTi a unit specific page nsite Hazardous Waste Treatment Notification•Uni afftra Waste and Treatment Process Combinations page for
<br /> each treatment unit at this location.
<br /> For notification requirements for PBR FTUs refer to 22 CCR 367450.2,for CA refer to HSC 325200.3(e)and (k),and for CE refer to HSC 325201.5(d)
<br /> and(i).
<br /> (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for
<br /> electronic submission and are the same as the numbering used in 27 CCR,Appendix C,the Business Section of the Unified Program Data Dictionary.)
<br /> Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are
<br /> separated.
<br /> 1. FACILITY ID NUMBER-Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility.
<br /> 3. BUSINESS NAME-Enter the full legal name of the business.
<br /> 600.NOTIFICATION STATUS-Check whether this notification is your initial notification under the Tiered Permitting system,an amended notification,or
<br /> a renewal(for PBR only).
<br /> 601.PERMIT STATUS-Check the status of the permit for State issued hazardous waste permits or grants of authorization.
<br /> 602.NUMBER OF UNITS-For each of the permitting fiers or categories listed,enter the number of units you operate at this facility location. Complete
<br /> a unit specific notification page and a waste and treatment process page for each unit you list here,except for CE-CL units. Verify that
<br /> the total number of units(item 602g)is equal to the number of unit specific notification and waste and treatment process pages induced in the
<br /> submittal plus the number of CE-CL units(item 602f).
<br /> SIGNATURE OF OWNER/OPERATOR-The business owner or officer of the company who is authorized to make decisions for the facility and who
<br /> has operational control,shall sign in the space provided. In most companies,this is not the environmental compliance or technical staff. The
<br /> title should indicate that an appropriately authorized person is signing for the company. Original signatures are required.
<br /> You are signing the certifications and attesting to their accuracy under penalty of law for submitting false information. The certifications cover
<br /> waste minimization,the eligibility of the units)for the indicated der,the fact that the unit meets all of the operating requirements for that tier,
<br /> and that the information is accurate. These operating requirements are set forth in the statutes and regulations.
<br /> 603. DATE CERTIFIED-Enter the date that the page was signed.
<br /> 604. OWNER/OPERATOR NAME-Enter the full printed name of the person signing the page.
<br /> 605. OWNER/OPERATOR TITLE-Enter the title of the person signing the page.
<br /> REQUESTING A SHORTENED REVIEW PERIOD-Generators operating under CA and CE are legally authorized 60 days after submitting a complete
<br /> notification. The time period between notificafion and authorization may be shortened when the owner or operator shows a good cause. Check whether
<br /> or not you are requesting to be authorized sooner than the standard 60-day period,and state the reason for the request. The authorization will be
<br /> automatically effective on the date the completed notification page is received by the CUPA. (If necessary,use additional sheets to explain your
<br /> reasons.) Generators operating under the PBR tier are not authorized until they are notified by the CUPA.
<br /> ATTACHMENTS NOTE: Commercial Laundries are not required to provide attachments.
<br /> ALL FACILITIES-
<br /> ete nit notificatio nd a aste and treatrnent rocess pag for EACH unit covered b this notifcation.
<br /> 2. Provide a alo a an or mai etailinc the location o—T�s oaf a uni is aality. This document is for use by the inspector.
<br /> Cleady indicate the d hamdaries antl major features. The extent or detail of the plot plan will vary depending on the size of the facility,
<br /> the extent of the industrial o erations,and the numTier of treatment units. A diagram prepared for the hazardous materials business plan
<br /> (required by i e CR)may be used,as long as the uni— t numbers7or the units covered by this notification are indicated.
<br /> PBR&CA ONLY
<br /> 1. Complete the Certification of Financial Assurance for Closure and attach here ormerl DTSC Form 1232 Check whether you have Self-
<br /> Certified(because your c osu cos are ess an 10,000)or if you are submitting a inanua mechanism.
<br /> 2. Prior Enforcement History information is required ONLY if this facility was the subject of any convictions,judgments,settlements or final
<br /> orders resulting from an action by any local,state,or federal environmental,hazardous waste,or public health enforcement agency. If
<br /> 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
<br /> document(conviction,settlement,etc.). The summary should include case and docket number,name and address of the agency,date,
<br /> brief explanation,type of case(criminal,civil,administrative)and final resolution(including fines and penalties).
<br /> ADDITIONAL SUBMISSION TO DTSC:
<br /> A PHASE I ENVIRONMENTAL ASSESSMENT IS REQUIRED FROM ALL PBR AND CA FACILITIES AND MUST BE SUBMITTED TO
<br /> DTSC,NOT TO YOUR CUPA. This assessment was due on January 1,1997 or withiri one year from initial notification for newer facilities.
<br /> Revisions are required if new releases are discovered.
<br /> The assessment checklist and instructions are available from DTSC. Call(916)324-2423 or write to DTSC-Unified Program Section,P.O.
<br /> Box 806,Sacramento,CA 95812-0806. Completed Phase I Assessments should be submitted to the same address.
<br /> PBR ONLY
<br /> 1. Tank and/or containment system certifications are required to be submitted for only PBR units by 22 CCR 3 67450.2(b)(3)(G),when
<br /> applicable. The specific standards are in 22 CCR 366264.175(c)for containers and 22 CCR 366265.191(a)and 66265.192(a)for tanks.
<br /> 2. Notification of local agencies. Attach documentation of the other local agencies notified of your operation,i.e.sewer agency.
<br /> 3. Notification of property owner. If the property owner is different than the operator,provide documentation that the facility operator has
<br /> notified the property owner of the operation of this hazardous waste treatment unit under PBR.
<br /> UPCF(12/99 revised) 21 Formerly DTSC 1772
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