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Sate of California-California Environm I Protection Agency a artment of Toxic Substances Control <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION - FACILITY PAGE <br /> Pa of <br /> BUSINESS NAME(game u rACNTY NAME or OBA Ibing Business As) <br /> s 1 FACILITY ID# <br /> O eT a Co, <br /> IL STATUS <br /> NOTIFICATION STATUS 600 FhKMIT STATUS(Check all that apply) 601 <br /> tla a Amended N]a Facility Permit ❑d Variance <br /> ❑b Initial ❑b Interim Status ❑e Consent Agreement <br /> ❑c Renewal(PBR Only) ❑c Standardized Permit <br /> HI. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of unitn you operate in each tier,attach one unit notification page for each unit except CE-CL) <br /> A Conditionally Exempt—Small Quantity Treatment(CESQT)(May not function under any other tier) <br /> B Conditionally Exempt Specified Wastesimam(CESW) <br /> C Conditionally Authorized(CA) <br /> D Permit by Rule(PBR) <br /> E Conditionally Exempt—Limited(CEL) <br /> F Conditionally Exempt Commercial laundry(CE-CL) (No unit page is required for laundries) <br /> O TOTAL UNITS(Must equal the number of unit notification pages attached plus the number of CE-CL units) <br /> IV. CERTIFICATION AND SIGNATURE <br /> 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 <br /> economically practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment. <br /> Tiered Permitting Certification I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and secondary containment requirements. 1 certify under penalty of law that this document and all <br /> attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the <br /> information submitted. Based on my inquiry of the person or persons who manage the system,or those directly responsible for gathering the information,the <br /> information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> I am aware that there are substantial penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> RE 2FO PERATOR DATE <br /> SI 603 <br /> AME OF OWNER/OPERATOR soa TITL FOWNER/OPERATOR acs <br /> K 6GSIa/ A9/GC lfto de-,e <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes ONo <br /> State Reason for Request <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)must submit: PBR ONLY <br /> er�r�1 One unit specific notification page and one treatment process page per unit ❑ 1 Tank and container certifications,if required <br /> Lq 2 Plot Plan(or other grid/map) ❑ 2 Notification of local agency or agencies <br /> ❑ 3 Notification of property owner,if different from business owner <br /> PBR @ CA ONLY: <br /> ❑ 1 Closure Financial Assurance(formerly DTSC form 1232) <br /> ❑ Self Certified(<$10,000) ❑ Other mechanism <br /> ❑ 2 Prior Enforcement History,if applicable <br /> UPCF(12/99 revised) 20 Formerly DTSC 1772 <br />