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out_ VV <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE ENVIRON <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATIO jE <br /> ES <br /> Page 1 of <br /> I. FACILITY IDENTIFICATION <br /> WSINESSNA?ff(gweasFACBILYNAAfBj(DBA-Doi euei—A) 3 FACHffYIDN <br /> Yrfsl�ef l�jl��lri S 1gA. YtulivJ t IS��itn <br /> II. STATUS <br /> NOTIFICATION STATUS Eta. PERMIT STATUS(Check all that apply) bot. <br /> ❑a. Amended Ma FacilityPermit ❑d. Variance <br /> ❑b. Initial ❑b. Interim Status <br /> ❑e. Consent Agreement <br /> [1c. Renewal(PBR Only) ❑c. Standardized Permit <br /> M. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of wits you operate in each tier.Attach one unit notification page for each wit except CE-CL) <br /> A. Conditionally Exempt–Small Quantity Treatment(CESQT)(May not function under any other tier.) bot <br /> B. Conditionally Exempt Specified Wastestream(CESW) <br /> C. Conditionally Authorized(CA) <br /> D. 1 Permit by Rule(PBR) <br /> E. Conditionally Exempt–Limited(CEL) <br /> F. Conditionally Exempt Commercial Laundry(CE-CL) (No unit page is required for laundries) <br /> G. TOTAL UNITS(Must equal the number of unit notification pages attached plus the number of CE-CL units.) <br /> IV. CERTIFICATION AND SIGNATURE <br /> Waste Minimization-I certify that I have a program in place to reduce the volume,quantity and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment. <br /> Tiered Permitting Certification- I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and secondary containment requirements. I certify under penalty of law that this document and all <br /> attachments were prepared=der my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the <br /> information submitted. Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the information, the <br /> information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> I am aware that therfare su tial pe lties for submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> SIGNA E R DATE 603. <br /> 61 zo t2 <br /> NAMEOF OWWNNES��/OPERATOR boa. TITLE OF OPERATOR bas. <br /> !/LD///A5 / v <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes ❑ No <br /> State Reason for Request: <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)must submit: PBR ONLY <br /> ®1. One unit specific notification page and one treatment process page per unit ®1. Tank and container certifications,if required <br /> ®2. Plot Plan(or other grid/map) ❑2. Notification of local agency or agencies <br /> ❑3. Notification of property owner,if different from business owner <br /> PBR&CA ONLY: <br /> r❑.1. Closure Financial Assurance(fomerly DTSC form 1232) <br /> M Self Certified(<$10,000) ❑ Othermechanism <br /> E]2. Prior Enforcement History,if applicable <br /> UPCF hwf1772f(1/99)-1/2 www.unidocs.org Rev.02/16/00 <br />