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p 5 X019 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �UG NO\A 1868 EAST HAZELTON AVENUE, STOCKTON, CA 95205 ONM�N� R\j GES (209) 468-3420 FAX(209)46M138 IgE UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION This notification shall be submitted in person or by certified mail, with return receipt requested i. FACILITY INFORMATION FACILITY NAME: EPA IDNUMBER: ` (TOT LOCATION/MAILING ADDRESS: FACILITY PHONE NO: (:� L y C`1> `) CIre CITY: ZIP CODE: FACILITY CONTACT NAME: CONTACT PHONENO: �-; a , ( '.) - C', D �L i r II. PROCESS DESCRIPTION TYPE OF AEROSOL CANS: \ A o\ ESTIMATED VOLUMES OR QUANTITIES TO BE PROCESSED MONTHLY: TREATMENT PROCESS OR PROCESSES DESCRIPTION: \' ak CCKY'NS G,s i'rr� t'��i av1 unci► � r�'Vn � �1,,ut� �f\U u C ► neD EQUIPMENT DESCRIPTION: t �� U, v` EQUIPMENT DESIGN CAPACITIES: TQC �� .�.,� Ceti✓�j S�� , � f�1bv`�� i�Q� C��`j III. HAZARDOUS WASTE TREATMENT RESIDUALS DESCRIPTION OF THE CHARACTERISTICS OF HAZARDOUS TREATMENT RESIDUALS: 1 \ di VNq\ DESCRIPTION OF MANAGEMENT OF ANY HAZARDOUS TREATMENT RESIDUALS: IV. CERTIFI ATION I 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 persons directly responsible for gathering the information, the information submitted is, to be the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. SIGNATURE': t DATE: NAME OF PERSO SIGNING (?ERT (CATION (PRINT): TITLE: 'Note: Per the CA de of Regulations, Title 22, section 66270.115 this notification must be signed as follows: • For a corporation: by a responsible corporate officer, e.g. president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person authorized to perform similar policy or decision-making functions, which govern the operation of the regulated facility, for the corporation. • For a partnership or sole proprietorship: by a general partner or the proprietor, respectively • For a municipality, State, Federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this section, a principal executive officer of a Federal agency includes: the chief executive officer of the agency, or a senior executive officer having responsibility for the overall operations of a principal geographic unit of thea enc e.., Regional Administrators of USEPA .