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SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 EAST HAZELTON AVENUE, STOCKTON, CA 95205 <br /> (209) 468-3420 FAX (209) 468-0138 <br /> UNIVERSAL WASTE AEROSOL CAN PROCESSING NOTIFICATION <br /> This notification shall be submitted In person or by certified mail,with return receipt requested <br /> I. FACILITY INFORMATION <br /> FACILITY NAME: EPA ID NUMBER: <br /> : Ac_ 9 AV (2.A Lb(n(D V_3 L 7-3-2, <br /> LOCATION MAILING DRES : FACILITY PHONE NO: <br /> _3I�' � J, aor-fir <br /> CITY: n ZIP CODE <br /> FAC TY CONTA NAME: i CONTACT PHONE NO: <br /> U ft�ju 120'?---SZ<) -606 o <br /> II. PROCESS DESCRIPTION <br /> TYPE OF AEROSOL CANS: <br /> ESTIMATED VOLUMES OR QUANTITIES TOBE PROCESSED MONTHLY: <br /> TREATMENT PROCESSOR PROCESSES DESCRIPTION: 124, Cpgg my r Lvrzetvy Cod Cn'vt�'r Sri <br /> e,jwj� oPleti0eleV1 �A' ;c }�C,tii �Ci-vshr a� ar�i� Criia �N fah <br /> EQUIPMENT DESCRIPTION: <br /> rI4�111 JOY Awa' FO Id �� k7 <br /> EQUIPMENT DESIGN CAPACIT S; <br /> ro <br /> III. HAZARDOUS WASTE TREATMENT RESIDUALS <br /> DESCRIPTION OF THE CHARACTERISTICS OF HAZARDOUS TREATMENT RESIDUALS: <br /> DESC PTION OF MANAGEME T OF,p HAZAR U TREATS�ENT RESIDUALS: <br /> �S � y rE? y- vstl• �I�f�,vy Loi> �i �/ f,Sa,' <br /> Raqc, plc�voYam,lc Wince , cvee�C <br /> IV, CERTIFICATION <br /> I certify under pen 1 law that this document and all attachments were prepared under my direction or supervision in accordance with a system <br /> designed to allJ"r, <br /> u lified personnel properly gather and evaluate the information submitted, eased on my inquiry of the person or persons who <br /> manage the systea persons directly responsible for gathering the information,the information submitted is, to be the best of my knowledge and <br /> belief, truY,accuracomplete. I am aware that there are significant penalties for submitting false Information,including the possibility of fine and <br /> im risonmenf farkviolations. <br /> SIGNA7UR : DATE: / <br /> � <br /> F W, <br /> —" (, 2D <br /> NA__NE. PERS9N SIGNING ERTIFICATION(PRINT): TI LE: <br /> 'Note: Per the/CA Code of Regulations,Title 22,section 66270.11,this notification must be signed as follows: <br /> • For a corporation: by a responsible corporate officer, e.g, president, secretary, treasurer, or vice-president of the corporation in charge of a principal <br /> business function,or any other person authorized to perform similar policy or decision-making functions,which govern the operation of the regulated <br /> facility,for the corporation. <br /> • For a partnership or sole proprietorship:by a general partner or the proprietor,respectively <br /> • For a municipality, State, Federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this <br /> section, a principal executive officer of a Federal agency includes: the chief executive officer of the agency, or a senior executive officer having <br /> rep_qnsibillty for the overall operations of a principal eo ra hic unit of thea enc e. ., Regional Administrators of USEPA. <br />