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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 /> BUSINESS NAME(Same as FACII-TTY NAME or DBA-Doing Business As) 3. 1 FACILITY ID#i <br /> Astelo Nk WAS <br /> II. STATUS <br /> NOTIFICATION STATUS 600. PERMIT STATUS(Check all that apply) 601. <br /> ❑a. Amended ❑a. Facility Permit ❑d. Variance <br /> M b. Initial ❑b. Interim Status ❑e. Consent Agreement <br /> ❑c. Renewal(PBR Only) ❑c. Standardized Permit <br /> M. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of units you operate in each tier. Attach one unit notification page for each unit except CE-CL) <br /> A. Conditional) Exempt—Small Quantity Treatment CES T)(�Ynot function under any other tier.) 602. <br /> B. Conditionally Exempt Specified Wastestream(CESW) RWoENED <br /> C. _� Conditionally Authorized(CA) A <br /> 014 <br /> D. Permit by Rule(PBR) L <br /> E. Conditionally Exempt—Limited(CEL) <br /> F. Conditionally Exempt Commercial Laundry(CE-CL) (No unit page is required for laundries.) <br /> G. TOTAL UNITS(Must equal the number of unit notification pages attached plus the number of CE-CL units.) <br /> IV. CERTIFICATION AND SIGNATURE <br /> Waste Minimization-I certify that I have a program in place to reduce the volume,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 treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment. <br /> Tiered Permitting Certification-I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and secondary containment requirements. I certify under penalty of law that this document and all <br /> attachments were prepared under my direction or supervision in accordance 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 persons who manage the system, or those directly responsible for gathering the information, the <br /> information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> I am aware theAthere are subF4ntial p 1 W s r submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> SIG F T .� DATE 603. <br /> N F WWNER/OP 604. TITLE OF OWNERIOP TO Eos. <br /> Micfia.1 Jr <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) Yes ❑ No <br /> State Reason for Request: `tit Ali Ci®i/y /5- h I <br /> f i ys (/hQ <br /> ead S ��Y 9/-' 0. YGp�,�Cq P `✓Cc S OtA <br /> a mcl re fpai F O��/�Ga1�/oil , Gi hcI �S I Yte�aOYTC.N 1` 7�v Q t��a 6�S/If�SSPS. <br /> rXe ko)RVAoat alp"cJCCtvea�w,`�yt taey �ssc�hti'a//y c/w/v /.cafes Ofl&vNC�a°f%®NG��y ,L}tef�i0{r/2C®f/J 0j0erAfet// 4>" l `1 CO—rANY Glf Rh GtpJ�etNh <br /> SilE n / axes 1,-&/C or 17o lames/T J-o Reoole or #e �°hv.'r®h�e•e7�. <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)must submit: PBR ONLY <br /> 14 1. One unit specific notification page and one treatment process page per unit ❑1. Tank and container certifications,if required <br /> 14 2. Plot Plan(or other grid/map) [12. Notification of local agency or agencies <br /> ❑3. Notification of property owner,if different from business owner <br /> PBR&CA ONLY: <br /> ®1. Closure Financial Assurance(formerly DTSC form 1232) <br /> X Self Certified(<$10,000) ❑ Other mechanism <br /> ❑2. Prior Enforcement History,if applicable <br /> UPCF hwfl772f(1/99)-1/2 www.unidocs.org Rev.02/16/00 <br />