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EPA ID NUMBER CAL nOO1O7712 Page 3 of 6 Vf. ATTACHMENTS: 0 1. A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries. ® 2. A unit specific notification form for each unit to be covered at this location. A VII. CERTIFICATIONS: This form must be signed by an authorized corporate officer or any other person in the company who has operational control and performs decision-making functions that govern operation of the facility(per title 22, California Code of Regulations (CCR) section 66270.11). All three copier mtert have original signatures, Waste Minimization I certify that 1 have a program in place to reduce the volume, quantity, and toxicity of waste generated to the degree I have determined to be economically practicable and that 1 have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health and the environment. Tiered Permittingrtifi tion 1 certify that the unit or urtica described in these documents meet the eligibility and operating requirements of state statutes and regulations for the indicated permitting tier, including generator and secondary containment requirements. I understand that if any of the units operate under Permit by Rule or Conditional Authorization, I will also be required to provide required financial assurances by January 1, 1994, and conduct a Phase I environmental assessment by January 1, 1995. 1 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 directly responsible for gathering the information, the information is, to the best of my knowledge and belief, true, accurate, and complete. 1 am aware that there are substantial penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. VERNA GALLERY ACTING C_E.O. Name (Print or Type) Title _'2 Signature Dan OPERATING REQUIREMENTS: Please note that generators treating hazardous waste onsite are required to comply with a number of operating requirements which differ depending on the tiers) under which one operates. These operating requirements are set forth in the statutes and regulations, some of which are referenced in the Tier-Specific Faasheers. SUBMISSION PROCEDURES: You must submit two covies of this completed not fcation by certified mail, return receipt requested, to: Department of Toxic Substances Control Form 1771 Onsite Hazardous Waste Treatment Unit 400 P Street, 41h Floor (walk in only) P.O. Boz 806 Sacramento, CA 95812-0806. u must also tubmir one cvw of the notification and attachments to the local regulatory agency in your jurisdiction as listed in the nrtruaion materia Ls. You must aLro retain a copy as pan of your operating record. All three forms must have original signatures, not photocopies. DTSC 1772 (1/93) Page 3