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STATE.OF CALIFO RNIA-ENVIRONMEN PROTECTION AGENCY PETE WILSON, Governor <br /> DEPARTMENT OF TOXIC SUBS7KNCES CONTROL <br /> REGION 1--10151 Croydon Way, Suite 3 <br /> Sacramento, CA 95827 <br /> CHECKLIST AND INITIAL VERIFICATION INSPECTION REPORT FOR <br /> Permit by Rule, Conditionally Authorized, and Conditionally Exempt Notifiers <br /> SIGNATURE SHEET <br /> Onsite Recycling: Only answer if this facility recycles mare than IM kilagram i anthqfhazardous waste onsite. <br /> NO <br /> 28. The appropriate local agency has been notified. HSC 25143.10 <br /> 29. Activities claimed under the onsite recycling exemption are appropriate. HSC 25143.2 et sec. <br /> Releases: If there has been a release,provide the following information:number of releases, date(s), type(s)and quantity of <br /> materialslwaste, and the cause(s). Use unit sheet or attach additional pages. <br /> YES <br /> 30. Within the last three years, were there any unauthorized or accidental releases to the <br /> environment of hazardous waste or hazardous waste constituents from onsite treatment units? <br /> 31. Within the last three years, were there any unauthorized or accidental releases to the <br /> environment of hazardous waste or hazardous waste constituents from any location at this <br /> facility? <br /> For purposes of a Tiered Permitting inspection, an unauthorized and/or accidental release to the <br /> environment does not include spills contained within containment systems. <br /> This report may identify conditions observed this date that are alleged to be violations of one or <br /> more sections at the California Health and Safety Code (HSC) or the California Code of Regulations, <br /> Title 22 (22 CCR) relating to the management of hazardous waste. The violations may be described in <br /> more detail on the attached note sheets. If any violations are noted, the facility is required to the submit <br /> a signed Certification of Return to Compliance within 30 days, unless otherwise specified. (A certification <br /> form is provided.) If any corrections are needed to the initial notification, the facility will submit a revised <br /> notification within 30 days to the Department of Toxic Substances Control with a copy to the local <br /> enforcement agency. <br /> Inspector(s): <br /> Lead r. n Other Inc r nr: <br /> Signatur • �� Signature: <br /> Print Name: 0 . A:s(,n Print Name: <br /> Title: s CAc)' T Title: <br /> Agency: 1 S L Agency: <br /> Phone Number: ql(, Phone Number: <br /> Facility Repr tative: <br /> Your signat re cknowle ges ei of this report and does not imply agreement with the findings. <br /> Signature: Print Name: is hzt V- r <br /> Title:G wt l-. i /t r�,-, Q � ,r Date: <br /> Onsite Checklist (C) Page -� of l c, January 1, 1995 <br />