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...( JAN 15 2003 <br /> FNVION nt iT HEALTH <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION - <br /> FACILITY PAGE <br /> Page I of _ <br /> L FACELITY IDENTIFICATION <br /> BUSINESS NAME(S�uFAl9.ITY NAAa?wDBA-pa'vy 8uonw.A,) 3. FACR.ITY IDB (, kKI 42 ,O 10 6 iGi'L <br /> Talc Td/ N/ cy 5'01_v71a;V5 j <br /> 00 /A/ TR/A�P-4AKb�R w7tC-A <br /> IL STATUS <br /> NOTIFICAUON STATUS I M. PERMIT STATUS Check all that I est. <br /> Fa.Amended I a FacilityPermit d Variance <br /> b.Initial b.Interim Status I e.Comer Aamernew <br /> c.Renewal R Only) i-- c.Standardised Permit <br /> HL NUMBER OF UNITS AT FACELI TY <br /> Undicatedienumberofunnayouopenaamembuer. Atbdmoneantsnotlfc m forembtale CECL <br /> A. Conditional) t-Small Quantity Treatment C not function under any other tier. eoz. <br /> B. Conditionally Exempt Specified Wasmstream CES <br /> C. Conditional) Authorized CA <br /> D. I Permit by Rule BR <br /> E. Conditional) Exem t-Limited CEL <br /> F. Conditionally Exempt Commercial Laundry CE-CL o unit is required for launilm. <br /> G. TOTAL UNITS use equal the number of unit notification pages attached plus the number of CE-CL units. <br /> IV. CERTIFICATION AND SIGNATURE <br /> t i -I certify that 1 have a prograrn in place to reduce the volume quantity and toxicity of waste generated to the <br /> degree I have determined to be economically practicable and that I have selected the practicable methad of treatment storaM or <br /> disposal cumntiy available to me which minimizes the present and future threat to human health and the environmeaL <br /> Tiered Permitting Certification-I certify that the unit or units described in these documents meet the eligibility and operating <br /> requirements of state statutes and regulations for the indicated permitting tier,including generator and secondary containment <br /> requirements. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision <br /> in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. <br /> Based on my inquiry of the person or persons who manage the system,or those directly responsible for gathering the information,the <br /> information' to the best of my knowledge and belief tate accurate,and complete. <br /> I mm aware that mere are substantial penalties for submitting false information,including the possibility of fines and imprisonrmemt <br /> for knowing violations. <br /> SIGMA P OI DATE em. / <br /> NAME OF OWNS TDLE OF OWNER/OPERATOR ens. <br /> lK 1 57 i'd1.Y7— <br /> REQUEST <br /> RE UEST FOR SHORTENED REVIEW PERIOD CE and CA Yes <br /> State Reason for Request <br /> V.ATTACHMENTS Check if attached <br /> ALL tiers mcept CE-CL dries must submit PBR ONLY <br /> 1.Ome unit s ific potification a and one lreaanent a unh 1.Tarok and¢mmminer ccrtificafionsif <br /> aired <br /> 2.Plot Plan(or other grid/map) 2.Notification of local agency or agencies <br /> Notification of property owner,if di6'erent <br /> from business owner <br /> PBR&CA ONLY: <br /> 1.Closure Finattcid Assurance(Camerly DTSC krm 1232) <br /> Self Certified(<510,000) Othermechanism <br /> 2.Prior Enforcement History,if applicable <br />