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i <br /> 1 <br /> EPA ID Number C A L 0 0 0 2 9 9 4=4 OMB# 2050- 0024 ; Expires 05/31 /2020 <br /> 16 . Notification of Hazardous Secondary Material ( HSM ) Activity <br /> ®Y [7,/ N Are you notifying under 40 CFR 260 .42 that you will begin managing, are managing, or will stop managing <br /> hazardous secondary material under 40 CFR 260 . 30, 40 CFR 261 . 4 ( a ) ( 23 ) , ( 24 ) , (25 ), or ( 27 ) ? If "Yes " , you <br /> must fill out the Addendum to the Site Identification Form for Managing Hazardous Secondary Material . <br /> 17 . Electronic Manifest Broker <br /> Ily R] N Are you notifying as a person , as defined in 40 CFR 260 . 10, electing to use the EPA electronic manifest sys- <br /> tem to obtain, complete, and transmit an electronic manifest under a contractual relationship with a haz- <br /> ardous waste generator? <br /> 18 . Comments ( include item number for each comment) <br /> NIA <br /> 19 , Certification I certify under penalty of law that this document and all attachments were prepared under my direction or su - <br /> pervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information <br /> submitted . Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gath - <br /> ering the information , the information submitted is, to the best of my knowledge and belief, true, accurate, and complete . I am <br /> aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for <br /> knowing violations . Note : For the RCRA Hazardous Waste Part A permit Application, all owners and operators must sign (see 40 <br /> CFR 270 . 10 ( b) and 270 . 11 ) . <br /> Signat 41 <br /> of legal o , op for oriz representative Date ( mm/dd/yyyy) <br /> 9!1212019 <br /> Printed Name ( First, Middle Initiast) Title <br /> Robert Chrisp President and Owner <br /> Email <br /> rchrisp@chrispco . com <br /> Signature of legal owner, operator or authorjzed representative Date ( mm/dd/yyyy) <br /> 9/1212019 <br /> i� <br /> Printed Name ( First, Middle Initial Last) Title <br /> William Buckman Safety Director <br /> Email <br /> bbuckman@chrispco . com <br /> EPA Form 8700- 12, 8700- 13 A/B, 8700-23 Page mmmmm <br /> 6 of 6 <br />