COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Clean Harbors Ellvirorunental Services,hc. California Land DisposaVRestriction lrrformation NotiflcalloWCarI fetation Form This fano is submitted in accenjanca with the req*enmts of 22 CCR 66M.7(a)chwter 1a wt*h rewicts land&Vosa of certain harardatswastes. The appropriate Caliiomia waste code(s)and etip�it ae r r-RCRA hates waste rQs from CCR 6 _29 are noted blow.Compiete all portions of Part#. tithe weme is norF hazardous or not rwrrkfed then complete only the a le portims in Part t and sign l date the Form a1 the hotIDan of page. Oftfwi$e complete Part 1,11,and 111. and sigrJd2te the Form at ftp bottom of gage.(For RCRA wastes,uas Goan Harbors RCf3A FORMS) 1. GENERAL INFORMATION REGARDflifG GENERATOR&WASTE STREAM [ D1E_StoW0n.LLC PHONE 2Qa-32E1~3 12-.5ITE_2526 West W on Street Stockton,CAL 95233 PROFILE NUMBER: _._CH6417M IS THIS WASTE NON HAZARDOUS? X NO El YES 4 3 I'f YES,stop here and sign1date form at the bottom of page) GENERATORS EPA ID#: __Q6=59102 MANIFEST q; CA WASTE CODE(q. IS THIS WASTE RESTRICTED? v YES INFO(W NO,stop here and sfgydate form at nite boffam ofpage) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMAT'IC W r t.(A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTI; EI(B)GENERATOR KNOWLEDGE OF THE WASTE;OR 0(C)BOTH Cheek the appropriate boxes in Pe is 11 and III_If a* ate,then ION is not required.For mtKjAe ,the appropriate choices from Part it(1.3)may tae marked in Part III(A)to hdkxde how waste Ls to be managedto crortfwm YAM Land Iii Resfrickm. By selecting an item in Part III(A),1-3,you are making the certification/notification noted in Part It. 11. TYPE OF LOR NOTIFICATION f CEHTWICATION 147 1 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO BEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:�22 CCR§66268.7(a)(1) 22 CCR§6626&7(a)(2) 1 certify underpenalty of law drat I personally have examined and am fan%war with the weave through analysis and lvsting through knon4edge of the waste to support this cerhfcafton drat the nowe tomplres with the treatrnsntstandards specified in CCR Tare 2Z Oivision 45,chapter 14 Amides 4 and l 1 and all appika6 a pmN/b#i0ns ser fwt/r in CCR Til b 21 Section 6&IM-2 or RCRA Section 3004fd)t42 U,5 G Section 69240))./believe drat the information/subs d!s tnne,aeacvraW and cornpAM&I am aware that there are significant penalties for submitting a fa/s�e cerlifrcatforr,including the pam Nifty ofa fine or imprisonrttent. 3.>NOTWICATION ata CE RT ATK*& NON41CRA WASTE THAT HAS BEEN TREATED AT AN OFF-MM TH ATNIENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCH AfiTKLE 11 TREATMENT STANDARDS:=:�22 CCR 666281171b)(5) 1 Certify unde3rpenalty of law that 1 personallyhave wean ined and am familiar with the waste dunugh ana/ysis and tesdng thrmigh b7on*me w Of Me waste to support this aernfirx=,that the Neste complies wr7h the treatment standards spe rifted in CCR Title 22,Dtvrseon LS,Chapter 18,Amides 4 and l l and all applka6Ae prohihNbns sat fotfh in CCR TiVe 22,SeMon 66 15&32 or RCRA Section 3W4(d)(42 U.S G.Section M40)./believe that the reformation/submitmd is truss,accurate and comp I am aware that them are sJ:7nfficantpenalties for submitting a false cardfleatlon,ined/uding the possibilrtyofa fine orinWrisonmeft M.LDR NOTOWATION/CERTMCATION 1W*F*1ATKJN FtE0LWjD8Y 22CCR = a Choat (A) 181 Ici lot apprep LL ar a ftol ham , intestwr�ion Prom �beaapory of Ramdcad Waste(22 CRR I OUL29 aKw)and Trewnerrt�Surodwd fPartdl Eflec"Da" TmaUbWFLV GmupWGIM140teNI-U1 tftan22CC114 7 irsm Aqueous wastes cvuaning morals t662ee.29lat a 86286.IM4 Zit 1 5UM107 Teale±I CLIM 11 02 s $fikol Auto shredderwe'ste t662O.ZXct&662e&1001&IMI 2 6M 106 Tahoe-A OCM L7 -�l 111191 Hemrdm a wash bundry sand 165269.29(a)&6=&l001aT(6)1 4 6626x.106 Table 1-9 CLV& -;.X 011 Dat € 1n151 Fly ash,bomn ash,ream ash or house wamta 1662&8-29#h1&e .t0el(aim) T 962BLIOG Table w MWE 4 C=1 D2 4n191 tla�ouse wade from rm►ndrie�s 166268.2911#& 700ia1f91i a 106 Table I-E LIME F Li 22 E3 3nm Aebeslae rnmairdq)waste identified in sect,[662M2Nmt&9MWlodat(i3)a 12 0626&114 � _3 otterlspedhft 13 Copses(A able treatment stantfatds and waste ana"data(whets avakNe)are Wined ad the fiaa its identified on the manifest referenced above. N. �aENERATORAUTHOR1ZATKWJCERTEICATIONr- I hereby that ati intormat ion sutantilted in this and aR associated documents is true,comphda.and a=mmde to the best of my k noMedge and Information,arld that no orrti areas a or rffst.I warrant that I am an authcxized representative of the ge nearator_ �d �r ;Nutf orhwd Si Printed Xame T-Ift AC Date THI;5 DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL a SUPPORTING DATA,MUST BE RETAINED BY THE GENEFIATOR FOR A LEAST FIVE(5)YEARS AS PER 2c CCR§6626x;.7 Rev.11/02 Page_of i 1!