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STATE OF CALIFORNIA-ENVIRONMEN"L PROTECTION AGENCY PETE WILSON, Governor <br /> DEPARTMENT OF TOXIC SUBb,ANCES CONTROL <br /> REGION 1--10151 Croydon Way, Suite 3 <br /> Sacramento, CA 95827 0 <br /> CHECKLIST AND INITIAL VERIFICATION INSPECTION REPORT FOR <br /> Permit by Rule, Conditionally Authorized, and Conditionally Exempt Notifiers <br /> SIGNATURE SHEET <br /> S IV�kltirJ p�rlT,� 1 C.l �p.l`i4�t) <br /> Onsite Recycling: only answer if this facility recycles more than lm kilagra,ne/month al'hazardous waste onsite. <br /> NO <br /> 28. The appropriate local agency has been notified. HSC 25143.10 <br /> 29. Activities claimed under the onsite recycling exemption are appropriate. HSC 25143.2 et sec. <br /> Releases: If there has been a release,provide rhe following information:number of releases, date(s), types)and quantity of <br /> materials/waste, and the cause(s). Use unit sheet or attach additional pages. <br /> YES <br /> 30. Within the last three years, were there any unauthorized or accidental releases to the <br /> environment of hazardous waste or hazardous waste constituents from onsite treatment units? <br /> 31. Within the last three years, were there any unauthorized or accidental releases to the <br /> environment of hazardous waste or hazardous waste constituents from any location at this <br /> facility? <br /> For purposes of a Tiered Permitting inspection, an unauthorized and/or accidental release to the <br /> environment does not include spills contained within containment systems. <br /> This report may identify conditions observed this date that are alleged to be violations of one or <br /> more sections at the California Health and Safety Code (HSC) or the California Code of Regulations, <br /> Title 22 (22 CCR) relating to the management of hazardous waste. The violations may be described in <br /> more detail on the attached note sheets. If any violations are noted, the facility is required to the submit <br /> a signed Certification of Return to Compliance within 30 days, unless otherwise specified. (A certification <br /> form is provided.) If any corrections are needed to the initial notification, the facility will submit a revised <br /> notification within 30 days to the Department of Toxic Substances Control with a copy to the local <br /> enforcement agency. <br /> Inspector(s): <br /> Tpad inspector; Other Tnspctnr: <br /> Signature: �' " Signature: /.1'U zl- BV •oQ� <br /> Print Name: TiM�gy Print Name: T(59 I?^(6cg I <br /> Title: FiSS Title: sc RF Hf <br /> Agency: Agency: 5FA704 4,; Co. <br /> Phone Number: (q(6 ) 755- 3043 Phone Number: <br /> Facility Representative: <br /> Your signatacknowledges receipt of this report and does not imply agreement with the findings. <br /> Signature: 1C , Print Name: �0"K li• <br /> Title: 4r`*� +t' Date: (D tl '15 <br /> Onsite Checklist (C) Page of 5 January 1, 1995 <br />