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Hazardous Materials/Waste Registration Form - Page 2 of 18
<br />RECEIVED
<br />D. Hazardous Waste Inventory Information (Hazardous Waste Generator Permit A; ca2i'k,�md.ndment)
<br />Complete the table below for all waste inventory. Use additional pages if needed.
<br />SAN JOAQUIN COUNTY
<br />OFFICE OF EMERGENCY SERVICES
<br />E. Additional Disposal Information
<br />For the following questions, check the appropriate box:
<br />1. Does this facility discharge process waste waters to sanitary sewer? ❑ Yes; ® No
<br />2. Does this facility generate infectious/biomedical wastes? ❑ Yes; ® No
<br />3. Does this facility store/handle radioactive materials? ❑ Yes; ® No
<br />F. Facility Site Plan/Storage Map
<br />Prepare and submit with this Registration Form a simple site map (see next page) which shows the following information:
<br />• North direction • Street(s) adjacent to facility • Location of storm drains • Electrical, water, and gas shutoff valves
<br />• Basic floor plan for each building containing hazardous materials/wastes which indicates building entrance(s) and hazardous
<br />material/waste storage locations (use grid locations or assign a code - A, B, C, etc. - to clearly identify each storage location for
<br />use in the above inventories).
<br />I declare that the above information is true and correct to the best of my knowledge. I agree to comply with all applicable
<br />regulations regarding storage, handling, and disposal of hazard s materia and hazardous or biomedical wastes.
<br />Steve Skanderson May 19, 2009
<br />Owner/Operator's Name (Print) Owner /Operator's Signature Date
<br />Definitions of Treatment/Disposal Methods
<br />Recycled on-site - The facility takes the waste or any constituent of the waste, treated or not, and reuses it on-site or ships it off-site as
<br />an Excluded Recyclable Material.
<br />Treated on-site - The facility employs any method, technique, or process which changes or is designed to change the physical,
<br />chemical, or biological character or composition of the hazardous waste or any material contained therein, or removes or reduces its
<br />harmful properties or characteristics for any purpose including, but not limited to, energy recovery, material recovery, or reduction in
<br />volume. (e.g. pH adjustment, evaporation, precipitation, filtration, distillation, compacting, etc.) If, after treatment, the material is
<br />reused at the facility, the "Recycled on-site" box in the waste inventory table should be checked.
<br />Shipped off-site for recycling/treatment/disposal - The facility sends the waste, or any hazardous treatment residual, to an off-site
<br />permitted treatment, storage, or disposal facility (TSDF).
<br />Note: Depending on how a waste or its constituents are recycled and/or treated, more than one treatment/disposal category may
<br />apply. All applicable boxes in column 2 of the waste inventory table should be checked.
<br />UN -012 - 2/18 http://www.unidocs.org Rev. 05/31/00
<br />Name of
<br />Treatment/Disposal Method(s)
<br />Max. Qty.
<br />Annual Qty.
<br />Location(s)
<br />Hazard
<br />Class
<br />Hazardous Waste
<br />(Definitions provided on bottom of page)
<br />(at any one time)
<br />Generated
<br />(see Section F)
<br />NONE
<br />Recycled on-site.
<br />Treated on-site.
<br />❑ gal.
<br />❑ lbs.
<br />❑ gal.
<br />❑ lbs.
<br />❑ Shipped off-site for recycling/treatment/disposal
<br />❑ cu. ft.
<br />❑ cu. ft.
<br />Recycled on-site.
<br />❑ gal.
<br />❑ gal.
<br />LJ Treated on-site.
<br />❑ lbs.
<br />❑ lbs.
<br />❑ Shipped off-site for recycling/treatment/disposal
<br />❑ cu. ft.
<br />❑ cu. ft.
<br />Recycled on-site.
<br />❑ gal.
<br />❑ gal.
<br />Treated on-site.
<br />❑ lbs.
<br />❑ lbs.
<br />❑ Shipped off-site for recycling/treatrnent/disposal
<br />❑ cu. ft.
<br />❑ cu. ft.
<br />Recycled on-site.
<br />❑ gal.
<br />❑ gal.
<br />LJ Treated on-site.
<br />❑ lbs.
<br />❑ lbs.
<br />❑ Shipped off-site for recycling/treatment/disposal
<br />❑ cu. ft.
<br />❑ cu. ft.
<br />Recycled on-site.
<br />❑ gal.
<br />❑ gal.
<br />Treated on-site.
<br />❑ lbs.
<br />❑ lbs.
<br />❑ Shipped off-site for recycling/treatment/disposal
<br />❑ cu. ft.
<br />❑ cu. ft.
<br />Recycled on-site.
<br />❑ gal.
<br />❑ gal.
<br />Treated on-site.
<br />❑ lbs.
<br />❑ lbs.
<br />❑ Shipped off-site for recycling/treatment/disposal
<br />❑ cu. ft.
<br />I ❑ cu. ft.
<br />E. Additional Disposal Information
<br />For the following questions, check the appropriate box:
<br />1. Does this facility discharge process waste waters to sanitary sewer? ❑ Yes; ® No
<br />2. Does this facility generate infectious/biomedical wastes? ❑ Yes; ® No
<br />3. Does this facility store/handle radioactive materials? ❑ Yes; ® No
<br />F. Facility Site Plan/Storage Map
<br />Prepare and submit with this Registration Form a simple site map (see next page) which shows the following information:
<br />• North direction • Street(s) adjacent to facility • Location of storm drains • Electrical, water, and gas shutoff valves
<br />• Basic floor plan for each building containing hazardous materials/wastes which indicates building entrance(s) and hazardous
<br />material/waste storage locations (use grid locations or assign a code - A, B, C, etc. - to clearly identify each storage location for
<br />use in the above inventories).
<br />I declare that the above information is true and correct to the best of my knowledge. I agree to comply with all applicable
<br />regulations regarding storage, handling, and disposal of hazard s materia and hazardous or biomedical wastes.
<br />Steve Skanderson May 19, 2009
<br />Owner/Operator's Name (Print) Owner /Operator's Signature Date
<br />Definitions of Treatment/Disposal Methods
<br />Recycled on-site - The facility takes the waste or any constituent of the waste, treated or not, and reuses it on-site or ships it off-site as
<br />an Excluded Recyclable Material.
<br />Treated on-site - The facility employs any method, technique, or process which changes or is designed to change the physical,
<br />chemical, or biological character or composition of the hazardous waste or any material contained therein, or removes or reduces its
<br />harmful properties or characteristics for any purpose including, but not limited to, energy recovery, material recovery, or reduction in
<br />volume. (e.g. pH adjustment, evaporation, precipitation, filtration, distillation, compacting, etc.) If, after treatment, the material is
<br />reused at the facility, the "Recycled on-site" box in the waste inventory table should be checked.
<br />Shipped off-site for recycling/treatment/disposal - The facility sends the waste, or any hazardous treatment residual, to an off-site
<br />permitted treatment, storage, or disposal facility (TSDF).
<br />Note: Depending on how a waste or its constituents are recycled and/or treated, more than one treatment/disposal category may
<br />apply. All applicable boxes in column 2 of the waste inventory table should be checked.
<br />UN -012 - 2/18 http://www.unidocs.org Rev. 05/31/00
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