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■% <br />11:310i FAX <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE, STOCKTON, CA 95205 <br />(209) 468-3420 FAX (209) 468-0138 <br />2018 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION <br />Tllis notl(Icatlon shall bo submitted in person or by certified mail, with return receipt requested <br />FACILITY INFORMATION <br />Received Time Dec, 3, <br />FACILITY NAME; <br />EPA ly NUMBER: <br />C cd 1 1 O ►'1 <br />C69A ©co e q 7--1 <br />-- <br />LOCATION/MA LING ADDRESS: <br />FACILITY PH Q NO: <br />���5 o W�4 �� <br />IoW 2 0 O <br />F, <br />CITY; k� <br />ZIP <br />3 <br />FACILITY CONTACT NAME: <br />CONTACT PHONE NO, <br />II. PROCESS DESCRIPTION <br />TYPE OF AEROSOL CANS: <br />/ <br />e qvc vu eA// <Fri yq <br />ESTIMATED VOLUMES OR QUANTITIES TO BE,, PROCESSF,D MONTHLY: <br />4o (c) Ca <br />TREATMENT PROCESS OR PROCESSES DESCRIPTION: <br />40 r'Fenye. <br />EQUIPMENT DESCRIPTION: <br />V� <br />EQUIPMENT DESIGN CAPACITIES; <br />oa CQ <br />III. HAZARDOUS WASTE TREATMENT RESIDUALS <br />DESCRIPTION OF THE CHARACTERISTICS Of HAZARDOUS TREATMENT RESIDUALS: <br />--� <br />DESCRIPTION OF MANAGEMENT OF ANY HAZARDOUS TREATMENT RESIDUALS: <br />CPA <br />IV. CERTIFICATION <br />I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system <br />designed to assure that qualified porsonncl properly gather and evalualc the informalion submitted. Based on my inquiry of the person or persons who <br />manage the system, or those persons directly responsible for gathering the information, the information submitted is, to be the best of my knowledge and <br />belief, true, accurate, an pee. m aware Ilial there are significant penalties for submitting false informalion, including the possibility of fine and <br />imprisonment for kno olalions, <br />SIGNATURE': --• <br />DATE: <br />(L J <br />NAME OF P I G CERTIFICATION (PRINT): <br />TITLE: <br />V� %V\ "\faa <br />al. Irl &V <br />_ <br />'Note: Per the CA Code of Regulations, Title 22, section 66270.111 this notification must be signed as follows: <br />For a corporation; by a responsible corporate officer, e.g. president, secretary, treasurer, or vice-president of the corporation in charge of a principal <br />business funclion, or ;4ny other person authorized to perform similar policy or decision-making functions, which govern the operation of the regulated <br />facility, for the corporation. <br />For a partnership or sole proprietorship: by a general partner or the proprietor, respectively <br />For a municipality, Slate, Federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this <br />section, a principal executive officer of a Federal agency includes: the chief exer:trlive officer of the agency, or a senior executive officer having <br />responsibility for the overall operations of a principal geographic unit of thea enc (e,g,, Regional Administrators of USEPA . <br />2018 10:32AM Flo, 4432 <br />