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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE, STOCKTON, CA 95205 (209) 468-3420 FAX (209) 468-0138 UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION This notification shall be submitted in person or by certified mail,with return receipt requested I. FACILITY INFORMATION FACILITY NAME: EPA ID NUMBER: �iwy,c5W_e_ us-vies rAl'q 2-1 zo 6212 Ll to Zia LOCATION/MAILING ADDRESS: FAC ITY PHONE NO: Z109-298- 1Vn ZIP CODE: FACILITY CONTACT NAME: CONTACT PHONE NO: _rJamie, Ll mo, II. PROCESS DESCRIPTION TYPE OF AEROSOL CANS: n lal� E5 IMATED VOLU ES OR OU NTITIES TO BE PROCESSED MONTHLY: a + TRID PROCESS OR PROCES EMSC RIPTION: so I CC•rl �O[ater a-�1 �-r� 1z4S .f o 41G r'28 CGf r1, ( n l me�c.�-i f EQUIPM T SCRIPTION: af o am SmSkn- EQUIPMENT DESIGN CAPACITIES, pu4(,We a pPrA 5-I6 aerosol cam '�6i36150mm-�v�►� dr III. HAZARDOUS WASTE TREATMENT RESIDUALS DESCRIPTION OF THE CHARACTERISTICS OF HAZARDOUS TREATMENT RESIDUALS: L� qWd WuWjaJ PH 54, Mubh point >73' r DESC(tIPTIOq OF MANAGEMENT OFANYHAZARDOUSTREATMENT RESIDUALS: n 55 Pon *e) cart,-m t cli,5 (fj oP in ICSS 4+)a4 L90 drzc S OS 01 RC 4 A KA cua wrc 0-- . IV. CERTIFICATION I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the information,the Information submitted is,to be the best of my knowledge and belief,true, accurate,and complete.I am aware that there are significant penalties for submitting false Information, including the possibility of fine and Imprisonment for knowing violations. SIGN A,rTpf2l / DATE: NAME OF LP-ERSO� NN SIGNNI G CERTI CATION(PRINT): TITLE: e V, P. O f d 'Note:Per the CA Code of Regulations,Title 22,section 66270.19,this notification must be signed as follows: • For a corporation:by a responsible corporate officer,e.g.president,secretary,treasurer,or vice-president of the corporation in charge of a principal business function,or any other person authorized to perform similar policy or decision-making functions,which govern the operation of the regulated facility,for the corporation. • For a partnership or sole proprietorship:by a general partner or the proprietor,respectively • For a municipality, State, Federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this section, a principal executive officer of a Federal agency includes: the chief executive officer of the agency, or a senior executive officer having res onsibil' for the overall o rations of a principal oe4raphic unit of thea en a 9..Regional Administrators of USEPA.