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w <br />APPLICATION FOR HOUSEHOLD HAZARDOUS WASTE ACTIVITY VARIANCE <br />RETURN TO: HOUSEHOLD HAZARDOUS WASTE UNIT <br />State Regulatory Programs Division <br />Department of Toxic Substances Control <br />700 Heinz Ave., Suite 210 <br />Berkeley, CA 94710-2737 <br />Public Agency <br />Applicant: San Joaquin County <br />Activity Location: Varies <br />City, State, Zip: <br />EPA ID #: CAH _ V A R I E <br />Contractor: MSE Environmental, Inc. <br />Contractor Address: 880 West Verdulem Street <br />City, State, Zip: Camarillo. CA 93010 <br />Contractor EPA ID #: CAD982504 <br />HW Hauler ID #: 2 6 4 8 <br />TYPE OF VARIANCE REQUESTED: Complete this application and submit with supporting information and <br />documentation identified on page 2 to the address shown above. <br />A. TYPE OF VARIANCE: (X) HHW ( ) CESQG ( ) Door -Door ( ) Mobile ( ) Other: <br />B. I am requesting a variance pursuant to California Health and Safety Code (HSC), section 25143, because the <br />following conditions apply: ATTACH SUPPORTING INFORMATION <br />( X ) The hazardous waste is solely a non-RCRA hazardous waste or the hazardous waste or its <br />management is exempt from, or is not otherwise regulated pursuant to Resource Conservation and <br />Recovery Act (RCRA); and meets one or both of the findings listed below <br />( X ) The hazardous waste or the hazardous waste management activity is insignificant or unimportant as a <br />potential hazard to human health and safety and the environment because of its small quantity, low <br />concentration and/or physical or chemical characteristics; and/or <br />( ) The handling, processing, or disposal of the hazardous waste, or the hazardous waste management <br />activity, is regulated by another government agency in a manner that ensures it will not pose a <br />substantial present or potential hazard to human health and safety and the environment. <br />CERTIFICATION <br />I certify under the penalty of law that this document and all attachments were prepared under my direction or <br />supervision in accordance with a system designated 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 persons <br />directly responsible for gathering the information, the information submitted in this application and attachment, is to <br />my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting <br />false information, including the possibility of fine and imprisonment for knowing violations. <br />Henry M. Hirata / Director <br />(Printed Name of Applicant) (Title) <br />Alison Hudson <br />(Printed name of Contact Person) <br />—(209) 468-3066 / (209)468-3078 <br />(Phone Number) (Fax Number) <br />(Rev 12/97) <br />C <br />l 3 s�98 <br />(Applicant's S' nature) (Date) <br />County of San Joaquin, P.O. Box 1810 <br />(Applicant's Address) <br />Stockton CA 95201 <br />(City) (State) (Zip) <br />