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APPLICATION FOf 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: County of San Joaquin Department of Public Works Activity Location: Various Sites throughout SJ Co (See attached list) City, State, Zip: EPA ID #: See attached list Contractor. MSE Environmental, Inc. Contractor Address: 880 West Verdulera Street City, State, Zip: Camarillo. CA 93010 Contractor EPA ID #: CAD 982504953 HW Hauler ID #: 2 6 4 8 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: ( ) HHW ( X ) CESQG ( ) Door -to -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 the Resource Conservation and Recovery Act (RCRA); and meets one or both of the findings listed below ( X ) The hazardous waste or 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 awar at there are sig7ifint7nalties for submitting false information, including the possibility of fine and i risonment r o 'ng viola 'ons. Alison Hudson / Management Analyst III A- (Printed Name of Applicant) (Title) Alison Hudson (Printed name of Contact Person) (209) 468-3066 (209) 468-3078 (Phone Number) (Fax Number) (Revised 8/01) (Applicant's Signature) (Applicant's Address) Stockton. CA 95201 (City) (State) (Zip)