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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION- FACILITY PAGE <br /> Page of <br /> I. FACILITY IDENTIFICATION <br /> BeSJ10(s m�� usm�a,sa) 3. FACILITY ID# t. <br /> �Z'NI H. STATUS <br /> NOTIFICATION STATUS 600. RMIT STATUS(Check all that apply) 601. <br /> ❑aa. Amended Facility Permit ❑d. Variance <br /> 9,b. Initial ❑b. nterim Status ❑e. Consent Agmen t <br /> ❑c. Renewal(PBR Only) ❑c. dardized Permit <br /> I. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of units a operate in each for. Attach one mit notification page for ea unit except CE-CL) <br /> A Conditionally Exempt—Small QuantityTrea ent(CESQT)(May not function under any other er.) <br /> B. Conditionally Exempt Specified Wastestream( SW) <br /> C. Conditionally Authorized(CA) <br /> D. Permit by Rule(PBR) <br /> E. Conditionally Exempt—Limited(CEL) <br /> F. Conditionally Exempt Commercial Laundry(CE-CL) (No it page is requir for laundries <br /> G. TOTAL UNITS(Must equal the number of notification pe s attach lus the number of CE-CL units.) <br /> IV. CERTIFICATI D SIGNATURE <br /> Waste Minimization-I certify that 1 have a program in place to reduce the vol ,quantity and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of trey t, forage,or disposal currently available to me which minimizes the present and <br /> future threat m human health and the environment. <br /> Tiered Permitting Certification- I certify that the unit or units described/dary <br /> se docurnims meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and Seco ontainment iequirements. I certify under penalty of law that this document and all <br /> attachments were prepared under my direction or supervision in accor ce with a system designed to assure that qualified personnel properly gather and evaluate the <br /> information submitted. Based on my inquiry of the person or s who manage the syst or those directly responsible for gathering the information, the <br /> information is,to the best of my knowledge and belief,true,accurate nd complete. <br /> I am aware that there are substantial penalties for submitting fats mformation,including the possibility o roes and imprisonment for knowing violations. <br /> Si A RE OWNER/OP TORP n DATE 603. <br /> dT'oU'/_ _� 5117/0 G <br /> NAME 017OWNER/OPERA OR 604. TITLE 9F OWNEFJOPERATO605. <br /> REQUEST FOR SHORTENED REVIEW PERIO (CE and CA only) ❑ Yes ❑ No <br /> State Reason for Request: \ <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE CL <br /> (La 'cs)must submit: PBR ONLY <br /> [31. One unit specific oo nation page and one treatment process page per unit ❑1. Tank and container certifications,if req a9 <br /> ❑2. Plot Pian(or oth d/map) ❑2. Notification of local agency or agencies <br /> ❑3. Notification of property owner,if different m It owner <br /> PBR&CA ONLY, <br /> ❑ I. Closure social Assurance(formerly DTSC form 1232) <br /> ❑ S Certified(<510;000) ❑ Othermechanism <br /> ❑2. Pri Enforcement History,if applicable <br /> UPCF hwf1772f(1/99)-1/2 http://www.unidoes.org \Rev.02/16/00 <br />