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CAD 4�3G 3 So ZY EPA ID NUMBER: Page_ of FACILITY NAME: INFORMATION STATUS: The information in the Notification Renewal Form is: . 1. Unchanged and correct. ❑ 2. Incorrect and has been corrected. ❑ 3. Amended to reflect operational changes of the facility which have occurred since the last notification (include attachments if applicable). Note: If adding new treatment units use the Unit Specific Fortes (1772B, C, D or L). CERTIFICATION: Phis form must be signed by an authorized corporate officer or any other person in the company who has operational control and performs decision-making functions that govern operation of the facility (per title 22, California Code of Regulations (CCR) section 66270.11). All three copies must have original signatures. 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 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 Permittin¢ 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. I am aware that there are substantial penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. Ga tz se . oos. rn9e. Name (Print or Ty Title :: e. 3 —a Z Signature f Date Signed OPERATING REQUIREII'IENTS: Please note that generators treating hazardous waste onsite are required to comply with a number of operating requirements which differ depending on the tier(s). These operating requirements are set forth in the statutes and regulations, some of which are referenced in the Tier-Specific Fact Sheets available from DTSC's regions or headquarters. SUBMISSION PROCEDURES: All three forms must have original signatures, not photocopies. You must submit two conies of this completed notification by certified mail, return receipt requested, to: Department of Toxic Substances Control Unified Program Section, HQ-10 Attn: Form 1772 RENEWAL 400 P Street, 4th Floor, Room 4453 (walk in only) P.O. Bax 806 Sacramento, CA 95812-0806 You must also submit one cony of the notification and new attachments to your local regulatory agency as listed in Appendix 2 of the instruction materials (also shown as a 'cc' to this letter. You must also retain a copy as part of your operating record.