COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

pan rumors Environmental Servicem,Inc. California Land Diso isal/Restriction Information Notn cation/Certification Form is form is submitted in aarordarrce wlh the requirement, of n CCR c£268.7(a) Chapter 18 which restricts lard disposal M certain hazardous wastes. The Pmpoare CaYlorNa arias c04(s)and appkPable nW4U?A hazardous wase ys*Vs from CCR 66266.29 are noted below.Complete all pmol,of Part I. If the Cale rt f0rMazmdausa natleshriedthen complete only the applicable persons in Pan I and sign f dale M Form W gle button of page. Olhervnse complete Part 1,and III,aro sigiVi ate me Form at the nater,of page.(Far RCRA wastes,use Clean Harbors RCRA FORMS) GENERAL INFORMATION REGARDING GENERATOR 8,WASTE STREAM 3ENERATOR'S NAME OTE Slptldon LLC PHONE: 2(19-.i2n3]14 SITE LOCJITION_25M W.WasNnglon 66ee[ 6tadRon,Cq 55203 1NOFtLE NUMBER: CH6n1753B IS THIS WASTE NON HAZARDOUS 7 XNO :J YES Ms.stop here arid,sfgi(date farm at tlfie be"of page) 3ENERATOR'S EPA IOC CALfI00359102 MANIFEST 4:Q(/E'8%On.'tt CAWASTE CODE(5): 571 IS THIS WASTE RESTRICTED? X YES NO(ff NO,stop hoe wdsyromN farm alt gm beep,ofpage) 1115 NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: (A)CHEMICI1lA'1IYSICAL'ANALYSfS OFTHE WASTE: O(B)GENERATORKNOWLEDGE OF THE WASTE:OR (C)BOTH lick the appropriate ones In Paris II Clod RI.If arty one applies.then IIIA)is not required.For multiple cerlifiratimsfnotificafions,the appropriate choices own Pad 15)may marked in Part 111(A)to Indicate IWw waste B to be managed to confann MIC"M Disposal Restrictions. By selecting an item in Pad III(A), 1-3,fou e making the codification/notfca ton weed in Part IL TYPE OF MR NOTIFICATION I CE3n1FlCATION 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE II TREATMENT STANDARDS:a 22 CCR§65268.7(a)(1) < 2:>NOTIFICATION a L'EITTRCATIDN:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:0 22 CCR 4662663(6112) I certify carder penalty of law Clan I peenma9Y hero--,--ad and an fsmhlw wfih she waste though enalys/s srM fesfis,fhmu9h knowledge o/ the waste la WAPOH ois combeebaR, Mat the waste cdmp/ies with the treatment standards speclmd in CCR Title 21,Dvision 4.5, Chapter 18, Articles 4 and II wed all applicable pmbbitlons set fiaith in CCR Tie 22 Section 66268.32 w RCRA Section 3004/0142 U.S.L. Section 6924(d)l.I bef'ew that flu ieVamo ion I subm fed is nue,aceunle and complete./mn swam dwf lax are signdcw.penahfes fwsubmfnfng a false cerb/ftd9en,inCiMVg ft possibility of a hide or impdswmlCnf. 3.>NOTIFICATION&CERTFICJITION: 1110"CRA WASTE THAT HAS BEEN TREATED AT AN OFFSITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TNEATME STANDARDS:>22 CCR 166268.7(b)15) /camfy undw penalty of law that/personalty hays examined wld am familiar with the waste through analysis and testing through knowledge of the waste to WAMirl this cahi/leabn,that Me waste complies with the l tmanf sta.Wards sper+Tedin CCR Ttle 22,D&W..4.8, C/raptw f6, Articles 4 a ll and ars appk ,b/e pmlubfRons set forth in CCR Title 22,Section 66268.32 m RCRA Section 3004(.1!42 U.S.C.Section 6924/dll./fxdieve shat Mc m/onnawn/submitted rs tare,acowa}e amt rnmp/efe./am avrem that dare am igr.firant peiWlfi6.s/orsubmittirg a /else certification,iWXMlnp the possibr/itY a/a ane w imprisonment. MR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCIi Ow[l W Cal Icl ml ppmeYla Cacl l,a.m 3hmn CanagoitlF® nears am6awi'n al RoalplEen 6u6oe1ppTel WebMe6 wm1e 122 CCR N266.a9 amtaW Trm-22c ina realer DleclM sere TilWWy6rupls166269.1OgaNl-161 (nm as CCW �I s A 1118/ap an.,emw wrrp wraeiig meu4lNtN.a&Y6Na6a.1 WCy1111 1 6 .107Tedeb CCYI fl :1 1'J $IQA1 .4rtn WpdJw MslaBY69.NM aN3a9.taalallAl i NIN.IN iawCw Gaye 'll @ 03 lnAl Ne:arOwe watts louMry t uJ I.a..2810 a.611.IWlY191 4 66266.1..1d C. 31 %2 J' holt Fly only povwv rn,caro,anw Walpuu.laaI6L2906 AN2a6.100WI11 T 6@6a.106 Tatla 1-0CCWE m C2 iH 1nAh Byrne anti ban twMries I62114136N 6 N2N.lamincel 6 NHILIWTaaaaliC of In @ vim I Patients marehrro wMti Warman n[xam lfi82N.2Ga1 16s2M.IWIvn LI 12 .111111. m :9 � oma Isaa=lrh v %opks at aPPA.bk heebraenl stmlderds end wa>[e analysis darn(where avatabk)are maklni.d a1lae fadNy HQtifnd w the manifest referenced above. . GENERATORAUTWR17ATIONACERTIFICATWH hereby certify Nat an infwmaton submitted in the and aA associated doalments is We,mnitete,arid nc-,Mate Vie best of my knowledge 30 Information,and hat no - cls m errors pmt.l woman alai I am m euglwc�e�d�mp//m_sertaove e/tle gene//natw. / dEz A.t�.n�, JOJlA/ '<'l y� ,,gr r r- Y 4 Zo lumonized na Fn Name TAk Date IIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL