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State of California-California Environmen I Protection Agency �15eartment of Toxic Substances Control <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION- FACILITY PAGE <br /> Pae of <br /> BUSINESS NAME(same as FACILITY NAME or DBA Doing Ruuue As) FACILITY IDH I <br /> TESD L Cc2PDaA ON <br /> II. STATUS <br /> NOTIFICATION STATUS 60) PERMIT STATUS(Check all that apply) 101 <br /> [,.,]/a Amended X. Facility Permit ❑d Variance <br /> J91, Initial [3 b Interim Status ❑e Consent Agreement <br /> ❑c Renews](PBR Only) ❑c Standardized Permit <br /> III. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of units you operate in each tier,attach one unit notification page for each unit except CE-CL) <br /> A Conditionally Exempt-Small Quantity Treatment(CESQT)(May not function under any other tier) wz <br /> B Conditionally Exempt Specified Wastestream(CESW) <br /> C Conditionally Authorized(CAI)1 <br /> OPermit by Rule(PBR) — <br /> E Conditionally Exempt-Limited(CEL) <br /> F Conditionally Exempt Commercial Laundry(CE-CL) (No unit page is required for laundries) <br /> G TOTAL UNITS(Must equal the number of unit notification pages attached plus the number of CE-CL units) <br /> IV. CERTIFICATION AND SIGNATURE <br /> Waste Minimization 1 certify that I have a program in place to reduce the volume,quantity and toxicity of waste generated to the degree 1 have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment. <br /> Tiered Permitting Certification I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and secondary containment requirements. I certify under penalty of law that this document and all <br /> attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the <br /> infomution submitted. Baud on my inquiry of the person or persons who manage the system,or those directly responsible for gathering the information,the <br /> information is,to the best of my knowledge and belief,true,accumte,and complete. <br /> I am aware at there are substantial penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> SIGN OF OR DATE 603 <br /> NAME OF OWNEWOPERATOR TITLE OF OWNER/OPERATOR 605 <br /> DAVID T wR `reR ANAL M ' R <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes WNo N% <br /> State Reason for Request <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)must submit: PBR ONLY <br /> 1 One unit specific notification page and one treatment process page per unit ❑ I Tank and container certifications,if required <br /> 2 Plot Plan(or other gridhnap) ❑ 2 Notification of local agency or agencies <br /> ❑ 3 Notification of property owner,if different from business owner—/Ja <br /> PBR&CA ONLY: <br /> I Closure Financial Assurance(formerly DTSC form 1232) <br /> 18(SelfCertified(<S 10,000) ❑ Other mechanism <br /> ❑ 2 Prior Enforcement History,if applicable <br /> UPCF(12199 revised) 20 Formerly DTSC 1772 <br />