COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Clean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information Notification/Certification Form This forth is submitted in accordance with the requirements of 22 CCR 66268.7(a)Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate California waste code(s)and applicable nal-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions N Part I. If the waste is non- hazardous or not restricted then complete only the applicable portions in Part I and sign/date the Form at the bottom of page. Otherwise complete Part 1,11, and III, and sign/date the Form at the bottom of page.(For RCRA wastes,use clean Harbors RCRA FORMS) 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM DTE Stockton,LLC PHONE 2()9-320-3712 SITE_2526 West Washington Street Stockton,CA.95203 PROFILE NUMBER: CH1346380 IS THIS WASTE NON HAZARDOUS If X NO =YES (d YES,stop here and sigNdate form at the bottom of page) GENERATORS EPA IDN: CAL00359102 MANIFEST N:0/lW3473FLE CA WASTE CODE(S): 571 IS THIS WASTE RESTRICTED? k YES NO(d NO,stop two and signidate tam at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: X(A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE; c(B)GENERATOR KNOWLEDGE OF THE WASTE;OR (C)BOTH Check the appropriate boxes in Parts It and III.It only one applies,then III(A) is not required.For multiple certhcations/notifications,the appropriate choices from Part 11(1-3)may be marked in Part III(A)to indicate how waste is to be managed to conform with Lard Disposal Restrictions. By selecting an item in Part III(A),1-3,you are making the certification/notification noted in Part It. IL TYPE OF LDR NOTIFICATION/CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 22 CCR§66268.7(a)(1) X -R>::�22 CCR§66268.7(a)(2) l certify underpenalty ofraw that 1 persona/ly have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this cartibcation,that the waste complies with the treatment standards specified fn CCR Tide 22,Ofv)sfon 4.5,Chapter 18,AiVeles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.SC Section 6924(d)).1 believe that the information/submitted is true,accurate and clompkim./am aware that there are signirmant penalties for submitting a false certification,including the possibility of fine or imprisonment. 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:>22 CCR §66266.7(b)(5) /certify underpena/ryoflaw that/persona//y have examined and am familiar with the waste through ana"is and testing through knowledge of the waste to support this certification,that the waste complies with the fmatmentstandards specified fn CCR Title 22,Division 4.5,Chapter 18,Articles 4 and 11 arida//applicable prohibitions set forth in CCR Title 22,Section 66266.31 or RCRA Section 3004(d)(42 U.S.0 Section 6924fd)).l believe that the information I submitted is true,accurate and Complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility ofa fine or imprisonment. Ill.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Ch.& (A) lel ICI IDI appropriate Check 1,2,or 3 hum Coneaponcling boxes handling information Prohibiter, Subrateponr of Restricted Waste 122 CCA 667b1.29 a+nl aM Treatment Stanch,! (pan 11 Effective Date Treatability Groupla)6U61.100(a)11-141 (From 22 CCR) 1 ".1 L2 3 112690 A9ueous wastes containing metals 16626FL29181&66268.10018.)(111 1 66268.107 Table II CCW 2. A '2 ":3 SM91 Auto chokkl r waste 166268.291.1&66268.1001x)1311 2 66268.106 Table-A CCWE 3. . _1 -_3 Vim Hazardous waste fo Mn,sand 168266.29(.16 68261L1001a11511 4 66MB.106 Table l-a 00AM 4.X -1 :zx 3 film Ryash,bosom ash.neon ash W beOwewaste(662Q29(h)&66269.100(x11811 7 USM106 Table I-D CCWE 5._: .-1 -2 3 111191 Baghouwwaste foan foundries 1IiM29(i)&66M.1001a)(911 8 66268.106 Table 1-FLWE 6. -1 �2 3 vim Asbestos mmaining waste iclendOe l in sem.n 186M8.29(ml&66268.1001a1(13)1 12 68268.114 7.= '1 -R -3 Other lSpedfy); 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above. IV. GENERATOR AUTHORIZATION/CERTIFICATION I hereby certify that all information submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omissions or errors�e>odst.I warrant that I am an authorized representative of the generator. ��a r��iAst✓��i^ A�xAs1 /'2��N rlat !-.-' Fr/T,trz✓ _�-�r,•�.Sc/r `��"S'/� -- Authorized SWalure Pr'rlted N1me Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CCR 666268.7 Rev.11/02 Page_of