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SAN J QA Q U I N Environmental Health Department <br /> -�v1"jTy <br /> Gran±r�ess grows ht. <br /> UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION <br /> I. FACILITY INFORMATION <br /> FACILITY NAME: EPA ID NUMBER: <br /> Nwwd) W 1LCh_W_ l_t I `7Z <br /> LOCATI N/M ILING ADDRE S: FACILITY PHONE NO: <br /> Son S, . P dci) I <br /> CITY: IP CODE: <br /> - n a432�c)3 <br /> FACILITY CONTACT NAME: CONTACT PHONE NO: <br /> �1 i (p�ab <br /> II. PROCESS DESCRIPTION <br /> TYPE OF AEROSOL CANS: <br /> A_ <br /> ESTIMATED VOLt JMrS OR QUANTITIES TO BE PROCESSED MONTHLY: <br /> TREATMENT PROCESS OR PROCESSES DESCRIPTION: <br /> CU�O� <br /> EQUIPMENT DESCRIPTION: <br /> EQUIPMENT DESIGN CAPACITIES: <br /> I <br /> III. HAZARDOUS WASTE TREATMENT RESIDUALS <br /> DESCRIPTION OF THE CHARACTERISTICS OF HAZARDOUS TREATMENT RESIDUALS: <br /> DESCRIPTION OF MANAGEMENT OF ANY HAZARDOUS TREATMENT RESIDUALS: <br /> T Wou A Jto�Azij U-v. 'wk—M I ij LID-t MON- O-S <br /> IV. CERTIFICATION <br /> I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system <br /> designed to assure that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of the person or persons <br /> who manage the system,or those persons directly responsible for gathering the information,the information submitted is,to be the best of my <br /> knowledge and belief,true,accurate,and complete.I am aware that there are significant penalties for submitting false information,including the <br /> ossibility of fine and imprisonment for knowing violations. <br /> SIGNATURE' DATE: <br /> l6 Z� <br /> NAME OF PERSM SIGNING dERTIFICATION(PRINT): TITLE <br /> 'Note:Per the CA Code of Regulations,Title 22,section 66270.11,this notification must be signed as follows: <br /> • For a corporation:by a responsible corporate officer,e.g.president,secretary,treasurer, or vice-president of the corporation in charge of a <br /> principal business function,or any other person authorized to perform similar policy or decision-making functions,which govern the operation <br /> of the regulated facility,for the corporation. <br /> • For a partnership or sole proprietorship:by a general partner or the proprietor,respectively <br /> • For a municipality,State,Federal,or other public agency:by either a principal executive officer or ranking elected official. For purposes of this <br /> section,a principal executive officer of a Federal agency includes:the chief executive officer of the agency,or a senior executive officer having <br /> resonsibilVv for the overall operations of a principal geographic unit of the agency(e.g.,R29ional Administrators of USEPA. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjgov.org/ehd <br />