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EPA II) NUMBER c� Page 3 of/I VI. ATI ACIIMENTS: ❑ I A plot plan/map detailing the liwanontsl of the covered untied in relation to the facility Mundanes ❑ _ .A unit src li, notification form for each unit to be covered at this location YI1. CERTIFICATIONS: This form must be signed by an authorized corporate officer or am other person in the comparr who hat operational control and performs derision-making funriions that govern operation of the facility(per title 22. California Code of Regulatiuns (CCR) section 66270.11) All three copies must haw original signatures. N aslc Minimir_Hion I certify that 1 have a program in place to reduce the volume. quantity. and toxicity of waste generated to the degree I have deternuned to be economically practicable and that I have selected the practicable method of treatment. storage. of disposal currently available to me which mimnuras the present and future threat to human health and the environment Tiered Pri-rnillinc Certification 1 certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and regulations for the indicated permuting tier, including generator and secondary containment requirements. I understand that if any of the units operate under Pemut by Rule or Conditional Authonration. I will also be required to provide required financial assurances by January 1. 1994, and conduct a Pfau 1 environmental assessment by January 1, 1995 1 certifv under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inguin 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 submitting false information, including the possibility of fines and impnsonment for knowmg vaolations. Name (Pant or Type) Title /303 Signature Date Signed OPERATING REQUIREMENTS: Please note that generators treating hazardous waste onsitr are required to comply with a number of operating requirements which differ depending on the tier(s) under which one operates. These operating requirements are set forth in the statutes and regulations, some of which an referenced in the Tier-Specific Fansheets. SUBMISSION PROCEDURES: You muse ,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, 41h Floor (walk in only) P.O. Box 806 Sacramento, CA 95812-0806. You must also submit one mm of the notlftcntion and attachments to the local regulatory agency in your junsdinion as listed in the instru lion matmakt. You must also retain a ropy as pan of your operating record. All three foots must have original signatures, not photocopies. DTSC 1772 (1193) Page 3