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EPA ID NUMBER GNDOOQ 14-L 9.79 Yage s of ti, <br /> `%we 9../ <br /> V1. ATTACIiMENTS: <br /> X1. A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries. <br /> ® 2. A unit specific notification form for each unit to be covered at this location. <br /> YII. CERTIFICATIONS: This form must be signed by an authorized corporate officer or any other person in the company who <br /> has operational control and performs decision-malting functions that govern operation of the facility(per title 22, California <br /> Code of Regulations (CCR) section 66270.11). AU three copier must have original signatures. <br /> Waste Minimization I certify that I have a program in place to reduce the volume, quantity, and toxicity of waste generated to the <br /> degree I have determined to be economically practicable and that I have selected the practicable method of treatment, storage, or <br /> disposal currently available to me which minimizes the present and future threat to human health and the environment. <br /> Ti red P rmitti rtification I erti 'that the tail or its r'bed in these d men meet the eligibili and o rating? <br /> requirements f tate statutes and re 1 toas for the indica[ tmitting tier, includin eaerator and secondary t <br /> requirements. understand that if any a units operate under rat t by Rule or Conditi Authorization, I will also required ; <br /> W provide financial a«+�nby anuary 1, 1994 ftdc duct a Phase I env' assessment by J 1, 5. <br /> 1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance <br /> with a system designed to assure that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry <br /> of the person or persons who manage the system, or those directly responsible for gathering the information, the information is, to <br /> 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 <br /> for knowing violations. <br /> lata_► P. N\;il_e,tib*;11A PI�.,a N\ata et^ <br /> Name (Print or Type) Title <br /> C)° C XGLJO>Zl— 3— ,3t— 3 <br /> Signature Date Signed <br /> OPERATING REQUIREMENTS: <br /> Please note that generators treating hazardous waste onsite are required to comply with a number of operating requirements which <br /> differ depending on the tier(s) under which one operates. These operating requirements are set forth in the stattues and regulations, <br /> some of which are referenced in the Tier-Specific Facrsheets. <br /> SUBMISSION PROCEDURES: <br /> You must submit two conic of this completed notification by terrified mail, return receipt requested, to: <br /> Department of Toxic Substances Control <br /> Form 1771 <br /> Onsite Hazardous Waste Treatment Unit <br /> 400 P Street, 4th Floor (walk in only) <br /> P.0. Box 806 <br /> Sacramento, CA 95812.0806. <br /> You must also submit one coon of the notification and attachments to the local regulatory agency in yourjurisdierion as listed in the <br /> instruction materials. You must also retain a copy as pan of your operating record. <br /> All three forms must have original signatures, not photocopies. <br /> DTSC 1772 (1/93) Page 3 <br />