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EPA ID NUMBER �laysyS�s�{ <br />M. RADIOACTIVE MATERIALS OR WASTE <br />_ YES NO _ <br />Does the facility use, store or treat radioactive materials or radioactive waste? <br />Page 2 of_ <br />Use either one or two SIC codes (a four digit number) that best describe your company's products, servicer, or industrial activity. <br />Example. 7384 ' Photof inishing tab 7118 Industrial Zatvtdn�ns <br />First: 34-11 At Second: <br />V. <br />PRIOR PERMIT STATUS: Check yes or no to each question: <br />YES <br />NO <br />1. <br />Did you file a PBR Notice of Intent to Operate (DISC Form 8462) in 1992 for this location? <br />0 <br />19 2. <br />Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim <br />status for any of these treatment units? <br />�q <br />3. <br />Do you now have or have you ever held a state or federal full permit or interim status for any other <br />hazardous waste activities at this location? <br />4. <br />Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br />are now notifying for at this location? <br />ED <br />❑ 5: <br />Has this location ever been inspected by the state or any local agency as a hazardous waste generator? <br />VI. PRIOR ENFORCEMENT HISTORY: Not required from generators only notifying as conditionally exempt or as a <br />commercial laundry. <br />YES NO <br />El29 Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or final <br />orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health <br />enforcement agency? <br />(Fos the'purposes of this form, a notice of violation does not constitute an order and need not be reported unless <br />it was not corrected and became a final order.) <br />❑ If you answered Yes, check this box and attach a listing of convictions, judgments, settlements, or orders and a <br />copy of the cover sheet from each document. (See the Instructions for more information) <br />VII. ATTACHMENTS: Altachmew are not required for Commercial Laundry facilities. <br />11 1. A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries. <br />2. A unit specific notification form for each unit to be covered at this location. <br />DTSC 1772 (1/95) . ' Page 2 <br />