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y ATl A('H!11IiNTti: ❑ I 4 phot plan,ntap detailing the locationlsl of the covered unmt,) to relation to the facility bcwndanes ❑ 4 unit src ilt, nottlication ham for each unit to be covered at this lo:atiun VIL CERTIFICATIONS: This form must he signed by an authorized corporate officer or any other person to the company test,, hue operational control and performs decision-making junctions that govern operation of the facility(per nNr 22, Cabfarni,: Crxie of Regulartow (CCR) section 66270.11) Ali three copies muff have onglrt l sigrixam. \1 rite Nliniminition I cently that I have a program in place to reduce the volume. quantity, and toxicity of waste generated to the degree I have determined to he ocononucally practicable and that I have selected the practicable method of treatment, storage, or dtsTxisal currently available to me which mrmrruzes the present and future threat to human health and the environment Tiered Permitting Certification 1 certify that the unit or uritis described to theca documents meet the eligibility and operatinv roquiremenL, of state statutes and regulations lot the indicated peril ting tier, including generator and secondary containment requirements I understand Nat if any of the units operate under Perrot by Rule or Conditional Authorization, I will also be mquirvJ to provide required financial assurances by January 1, 1994, and conduct a Phase 1 environmental assessment by January 1. 1995 I certify under penalty of law that Lisa document and all attachments were prepared under my direction or supervision in accordancr V,nh a system designed to assure that qualified personnel properly gather and evaluate the information subrmtted. Based on my ingmn of the person or persons who manage the system, or those directly responsible for gathering the information, the information is, to the best of my knowledge and belief, true, accurate, and complete. 1 am aware that there are substantial penalties for submstting false information, including the possibility of fines and imprisonment for knowing violations. K L-1" F(-. � P f C � Name (Peat or Type) Title Signature Date Signed OPERATING REQUIREMENTS: Please note that generators treating hazardous waste onsite are required to comph• with a number of operating requirements which differ depending on the Iter(s) under which one operates. These operating requirements are set forth in the statutes and regulation+, some of which are referenced in the Tier-Specific Facisheers. SUBMISSION PROCEDURES: You must submit two copies of this completed notification by certified mail, return receipt requested, to: Department of Toxic Substances Control Form 1772 Onsite Hazardous Waste Treatment Unit 400 P Street, 4th Floor (walk in only) P.O. Box 806 Sacramento, CA 95811-0806. You must also submit one win of the not fication and attachments to the local regulatory agency in your jurudicrion as fisted in the insrrunton maienaLs. You must also retain a copy at pan of your operating record. All three forms mart have original signatures, not photocopies. DTSC 1772 (1197) hje 3