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UNIFIED PROGRAM CONSOLIDATED FORM <br /> • HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION- FACILITY PAGE <br /> Page 1 of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(s...FAcu=NM�mDBA-roias.0 As) �' FACILITY ID# t <br /> P2c_nt e2 Cost-t.a 4" SST/ae,Ktx� <br /> •.J•J M9 <br /> II. STATUS <br /> NOTIFICATION STATUS 600. PERMIT STATUS(Check all that apply) bot. <br /> ❑a. Amended J4 a Facility Permit ❑d. Variance <br /> Ab. Initial ❑b. Interim Status ❑e. Consent Agreement <br /> ❑c. Renewal(PBR Only) ❑c. Standardized Permit <br /> III. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of units you operate in each tier. Attach one unit notification page for each unit except CE-CL) <br /> A. Conditionally Exempt—Small Quantity Treatment(CESQT)(May not function under any other tier.) 602' <br /> B. Conditionally Exempt Specified Wastestream(CESW) <br /> C. Conditionally Authorized(CA) <br /> D. 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 1 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 under 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 awe t t there s stant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> SI=OF TOR DATE 603. <br /> S 2 4 II <br /> WjAffAE <br /> OF O ER/OPERATOR boa. TITLE OF OWNERIOPERATOR 60T <br /> - <br /> I CL tr) <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 /> 91. One unit specific notification page and one treatment process page per unit ❑ I. Tank and container certifications,if required <br /> [k2. 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 /> • I. Closure Financial Assurance(formerly DTSC form 1232) <br /> W SelfCertified(<$10,000) ❑ Other mechanism <br /> ❑2. Prior Enforcement History,if applicable <br /> UPCF hwfl772f(1/99)-1/2 www.unidms.org Rev.02/16/00 <br />