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CALIFORNIA DEPARTMENT OF HEALTH SERVICES Page 2 <br /> Hazardous Waste Management Branch <br /> ¢�sa\s Manase% <br /> APPLICATION FOR CALIFORNIA EXTREMELY HA OUS WAS RMIT <br /> Con)pany "TkAc1Y IN <br /> 'T C.19Cut1 90hQity i 21�C t�° <br /> C-11--.0 a a (0G Zb6 S'6 <br /> r AVN � 0 a menti <br /> • pep <br /> p� QUANTITY <br /> Description of Waste: �� On One Time Basis: <br /> (lnelUding Corrrposition udtll Waste (:umponcnt(s) l pper l.e BERKEL PP"t Number: Units: <br /> UMxr caul Lower Cotuentraticnl <br /> of Hazardous Contpemoits) F 3O 0. 1 <br /> �}f F <br /> WASTE 3� Q�� Onl'car'sPcrrnit: <br /> 1 a <br /> cr <br /> P1)i.xx,il <br /> A BE Q (c t'd <br /> )cr Ycar �c,t'dl Z �M <br /> Description of Packaging, Containerization and Transport: 1)runls ❑ Cartons ❑ Bottles ❑ Tank Truck <br /> ❑ Othcr <br /> PROPOSED METHOD <br /> OF DISPOSAL XBurial ❑ Ponding, ❑ Storage" ❑ Incineration ❑ Other (Specify): <br /> ❑ Treatment (Specify): <br /> ❑ Recycling, (Sp(,cify method of reuse): <br /> Awla'Qblt' Coll tail leri_ itioll, ,111(1 transport of the mat('rial shall be ill accor(hmce frith Title' 49, Code of I r(lcral <br /> R('t11t1�1t1Ull� fOr IIiJ_�11"(1U/1? IN�Jt('YIcI��, Jll(111'Itll I(',EI11lcJtlU11So' tl1 , CIli' rllia HiQrlltva_\ Patrol, Iltl(' 1.3, C,Ilij* PSI <br /> .'111111i11lstrathw �.odc, fUl" Illtra tare trtvisport of hazar(lolls Materiols ii11(1, for 11( Ii-collta llill.l 11"Ut('S, !ll tICCOIY1- <br /> A111cc with t'.S.I:.P.A. rc't11rhltion s('t fort/l ill Title 40 CI:R Part 761. <br /> xCheck if additional wastes are described on page 3 of 3. <br /> PERi\11T TO BE USED FOR: (Length of Time) <br /> ❑ On a one time basis <br /> For a period of one year from date of issue CSC <br /> PERMIT RENEWALS: .application for renewal of a one-year blanket permit, using this form, must be received ar least 15 days <br /> prior to expiration date to keep permit hi effect. ,No reminder of the need to renew will be sells. <br /> For renewal,send a copy of existing permit with corer letter rc quectiny!any additional amendments. <br /> "Storage means holding at an off-site facility for greater than 72 hours. (Section 66192, Title 22, CAC) <br /> NUi9(w(, <br />