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APR. S. 1999 9:35Arl CAL/EPA DISC — Hwr•1P <br />N0.919 P.2:'3 <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 Agcy _ SAN JOAQUIN COUNTY <br />Appli=: PUBLIC WORKS DEPARTMENTContractor: <br />Activity Location: SAN JOAQUIN COUNTY Contractor Address: <br />City, State, Zip: STOCKTON, CA 95202 City, State, Zip: <br />EPA ID #: CAH , _ _ _ — T , _ _ Contractor EPA ID tf : <br />HW Hauler ID #: <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: ( ) HHW ( ) CES Transportatio <br />QG ( ) Door -to -Door ( )Mobile (X1 Other,Manifesting <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 />�) 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 the Resource Conservation and <br />Recovery Act (RCRA); and mc*ts ont or both of the findings lisied below <br />(� The hazardous waste or 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 quandry, 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 />CER1 uTcATION <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 cvahratc the <br />information submitted. Bated on my inquiry of the person or persons who manage the system, or those persons <br />directly responsible for gadlering the informatirni. the'information submitted in this application and attachment, is to my <br />knowledge and belief, true. accurate, and complete, I am aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imprisonment for knowing violate <br />HENRY*M. HIRATA DIR4CTOR OF PUBLIC WORKS <br />(Printed Name of Applicant) (Title) (Applicant's ) (Date) <br />TOM HORTON <br />(Printed name of Contact Person) <br />(Revised 5198) <br />P.O. BOX 1810 <br />(Applicant's Address) <br />(City) (State) (Zip) <br />