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APPLICATION FOR HOUSEHOLD HAZARDOUS WASTE ACTIVITY VARIANCE RETURN TO: HOUSEHOLD HAZARDOUS WASTE UNIT State Regulatory Programs Division Department of Toxic Substances Control 700 Heinz Ave., Suite 210 Berkeley, CA 94710-2737 Public Agency Applicant: San Joaquin County Contractor: MSE Environmental. Inc. Activity Location: San Joaquin Delta Colles Contractor Address: 880 West Verdulera Street Activity Address: Shima 2 Lot 5151 Pacific Ave. City, State, Zip: Camarillo. CA 93010 City, State, Zip: Stockton, CA Contractor EPA ID #: CAD982504953 EPA ID #: CAH 1J_ 1 0 0 0 2 0 7 HW Hauler ID #: 2__�_ 4 TYPE OF VARIANCE REQUESTED: Complete this application and submit with supporting information and documentation identified on page 2 to the address shown above. A. TYPE OF VARIANCE: (X) HHW ( ) CESQG ( ) Door -Door ( ) Mobile ( ) Other: B. I am requesting a variance pursuant to California Health and Safety Code (HSC), section 25143, because the following conditions apply: ATTACH SUPPORTING INFORMATION ( X ) The hazardous waste is solely a non-RCRA hazardous waste or the hazardous waste or its management is exempt from, or is not otherwise regulated pursuant to Resource Conservation and Recovery Act (RCRA); and meets one or both of the findings listed below ( X ) The hazardous waste or the hazardous waste management activity is insignificant or unimportant as a potential hazard to human health and safety and the environment because of its small quantity, low concentration and/or physical or chemical characteristics; and/or ( ) The handling, processing, or disposal of the hazardous waste, or the hazardous waste management activity, is regulated by another government agency in a manner that ensures it will not pose a substantial present or potential hazard to human health and safety and the environment. CERTIFICATION I certify under the penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designated to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted in this application and attachment, is to my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Henry M. Hirata / Director (Printed Name of Applicant) (Title) Alison Hudson (Printed name of Contact Person) (209) 468-3066 1 (209) 468-3078 (Phone Number) (Fax Number) (Rev 12/97) ,3zs9B (Applicant's 'nature) (Date) County of San Joaquin. P.O. Box 1810 (Applicant's Address) Stockton CA 95201 (City) (State) (Zip)