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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION- FACILITY PAGE <br /> Page 3 of 6 <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAe1E(Sameer FACa.rrYNA -DBA-Doing Brvmen Aa) ` FACILITYIDM I. <br /> Thule Towing Systems, LLC <br /> 11 STATUS <br /> NOTIFICATION STATUS nom. PERMIT STATUS(Check all that apply) tial. <br /> ❑a. Amended ®a. FacilityPermit ❑d. Variance <br /> ®b. Initial ❑It. Interim Status ❑e. Consent Agreement <br /> ❑c. Renewal(PBR Only) ❑c Standardized Permit <br /> HL 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.) eet <br /> B. Conditionally Exempt Specified Wastestream(CESW) <br /> C. Conditionally Authorized(CA) <br /> D. 1 Permit 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. 1 TOTAL UMTS(Must equal the number of unit notification pages attached plus the number of CE-CL units.) <br /> IV. CERTIFICATION AND SIGNATURE <br /> Waste Minimization-I certify that I have a program in place to reduce the volume,quantity and toxicity of waste generated to the degree 1 have determined W 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 /> information submitted. Based 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,accurate,and complete. <br /> I am aware that there are substantial penalties for submitting false information.including die possibility, of fines and imprisonment for knowing violations. <br /> SIGNATURE OF OWNER/OPERATOR DATE tat <br /> NAME OF OWNER/OPERATOR eoa. TITLE OF OWNER/OPERATOR ems. <br /> Tom McMillan VP of Finance <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ® Yes ❑ No <br /> State Reason for Request: <br /> Wastes will be generated starting in mid-January. Treatment system needs to be up and running as <br /> soon as possible. <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)must submit: PBR ONLY <br /> ®1. One unit speck notification page and one treatment process page per unit ❑1. Tank and container certifications,if required <br /> ❑2. Plot Plan(or other grid/map) E]2. <br /> Notification of local agency or agencies <br /> ❑3. Notification of property owner,if different from business owner <br /> PBR&CA ONLY: <br /> ®1. Closure Financial Assurance(formerly DTSC form 1232) <br /> ® Self Certified( $10,000) ❑ Other mechanism <br /> ❑2. Prior Enforcement History,if applicable <br /> CDMS/WKM/1-08 <br /> ITCF hwn772f(1/99)-112 www.unidocs.org Rev.02/16/00 <br />