COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Clean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information Notification/Certification Form This fort 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 non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions of 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 I,It,and III, and sign/date the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS) I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM DTE Stockton,LLC PHONE:,209-320-3712 SITE_2526 West Washington Street Stockton,CA.95203 PROFILE NUMBER: CH1346380 IS THIS WASTE NON HAZARDOUS? X NO L YES (if YES,stop here and sjgWbate form at the bottom of page) GENERATOR'S EPA ID#: CAL00359102__-__ MANIFEST#:0115M75/ CA WASTE CODE(S): 571 IS THIS WASTE RESTRICTED? X YES NO(if NO,stop here and sign/date form at the bottom of page) THIS NOTIFICATION ii CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: V(A)CHEMICAUPHYSICAL ANALYSIS OF THE WASTE; D(B)GENERATOR KNOWLEDGE OF THE WASTE;OR El(C)BOTH Check the appropriate boxes in Parts II and Ill_If only one applies,then III(A) is not required.For multiple certificatonsfnot[ficatlons,the appropriate choices from Part 11(1�3)maybe marked in Part III(A)to indicate how waste into be managed to conform with Land Disposal Restrictions. By selecting an item in Part III(A), 1-3,you are making the certification/notification noted in Part II. [I, TYPE OF LDR NOTIFICATION/CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT.CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE t t TREATMENT STANDARDS:=>22 CCR§66268.7(a)(1) Xr]i��22 CCR§66268.7(a)(2) 1 certify underpenaltyof law that 1 personally have examined and am familiar with the waste through analysis and testing th rough knowledge of the waste to support this certification,that the waste complies with the treatment standards specified in CCR Title 22,Division 4.5,Chapter 18,Articles 4 and I I and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 024(d))./believe that the information I submitted is true,accurate and complete.lam aware that there are significant penalties for submitting B false certification,including the possibility of a fine or impffsonment. ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACIIJTY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:='22 CCR 966268.7(b)(5) I certify underpenaltyoflawthat Ipersonallyhave examinedandam familiar with the waste through analysis and testing through knowledge of the waste to support this certification,that the waste complies wish the treatment standards specified in CCR Title 22,Division 4.5,Chapter 18,Articles 4 and I 1 and all applicable prohibitions set forth in CCR Title 22,Section 66265.32 or RCRA Section 3004(d)(42 U.S.C.Section 69240).1 believe that the information I submitted is tnle,accurate and complete.1 am aware that there are significant penalties for submitting a false certifreation,including the possibility of a fine or imprisonment. IN,LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR � check (Al (a) - (C) ffa) appropriate Check LLor9from corresponding boxes hsndkq information Prohibition Subcategory of RseMetad Waste(22 CCR 66268.29 s-rn)and Treatnant Standard (Part 11 Efteadve Date TrsetabNity.Groupla)f16268.100WI.141 (From 22 CCR[ 1.0 ❑t 02 713 1126M Aqueous wastes containing metals[6626B.29fal&66268.100fa)(111 1 66268.107 Table It CCW 2.u 01 132 [13 5/8/91 Auto shredderwaste[6ams.29(c)&66268.100(a)(3)) 2 66268.106 Tahla-A CCW[ 3, L1 02 E3 111/91 Hazardous waste foundry sand f66268.29(s)&66266.1D0(a)(5)] 4 66268.106 Table 1-8 CCW[ 4.X 01 112X 3 111191 Fly ash,bottom ash,retort ash or baghause waste 166268.29(h)&66268.100(a)(811 7 86268.105 Table I-0 CCWE 5. 01 72 03 1/1191 Baghouse waste from foundries[66268.29(4)&66268.100(a)(9)I 8 66268.106 Table I-E CM 6.0 Ct 02 Z3 3!1193 Asbestos containing waste identified in section[6626B.29(m)&66268.100(a)(1311 12 66268.114 7.n 71 r2 73 Other(Speclfy): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility ldenlif led on the manifest referenced above. IV. GENERATOR AUTHORIZATIONICERTIFICATION I hereby certify that all information submitted in this and all associated documents is true,cornpiete,and accurate to the best of my knowledge and information,and that no omissions or errors exist.I warrant that I am an authorized representative of the generator. /--5-tel 1A as r uthorized ' ature Printhd Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MIDST 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§66268.7 Rev.11102 Page_of