HomeMy WebLinkAboutHAZARDOUS WASTEState of California - California Environmental Protection Agency Department of Toxic Substances Control
- Page 1 of "7
ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM
FACILITY SPECIFIC NOTIFICATION [] Initial
For Use by Hazardous Waste Generators Performing Treatment [~ Amended
· Under Conditional Exemption and Conditional Authorization,
and by Permit By Rule Facilities
Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this
notification form, DTSC 1772. You must attach a separate unit specifiC notification form for each unit at this location. There are
different unit specific notification forms for five of the categories and an additional notification form for transportable treatment units
(ITU's). You only have to submit forms for the tier(s)/category(ies) that cover your unit(s). Discard or recycle the other unused
forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at
the 'Page __ of__'. Put your EPA ID Number on each page. Please provide all of the information requeste& all fields must be
completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any
attachments.
The notification fees are assessed on the basis of the highest tier the notifier will operate under and will be collected by the State
Board of Equalization. DO NOT SEND YOUR FEE.PAYMENT WITH THIS NOTIFICATION FORM.
I. NOTIFICATION CATEGORIES
Indicate the number Of units you operate in each tier. This will also be the number of unit specific notification forms you
must.attach. Conditionally Exempt Small Quantity Treatment operators may not operate units under any other tier.
Number of units and attached unit specific notifications for each tier reported.
A. ~ Conditionally Exempt-Small Quantity Treatment (CESQT) D. Permit by Rule (PER)
B. i Conditionally Exempt-Specified Wastestream (CESW) E. __ CE--Commercial Laundry (CE-CL)
C. Conditionally Authorized (CA) F. Conditionally Exempt-Limited (CEL)
II.- GENERATOR IDENTIFICATION
EpA ID NUMBER CA'~ 0 19 19_.0 ~) ~'~'_.~'0~' BOE NUMBER (if available) H__HQ~ ·
FACILITY NAME MA b~,~ tS~t/~ ~ ,.:~ ~2,op
(DBA--Doing Business As)
PHYSICAL LOCATION ~/0 E/-/~ 7'~' /~V~g//d ~
COUNTY
CONTACT PERSON "~A°/~ ~ ~/~4 ~/..~) PHONE NUMBER(~05)
(First Name) (Last Name)
MAILING ADDRESS, IF DIFFERENT:
COMPANY NAME /MC.
CITY ~UA~g~ ti4 STATE A/~-- ZIP ~
COUNTRY
(only complete if not USA)
CONTACT PERSON ,,_")"/q I t~ t ~-, "~ka/SJ(~ C/.- PHONE NUMBE~(g/c
(First Name) (Last Name)
DTSC 1772 (1/96) Page
EPA ID NUMBER CA~ QC},-.~3~/t 'Page 2 of~
IH. RADIOACTIVE MATERIALS OR WASTE
YES NO ,,
[--] [~ Does the facility use, store or treat radioactive materials or radioactive waste?
IV. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE:
Use either one or two SIC codes (a four digit number) that best describe your company's products, services, or industrial activity.
Example: 7384 Photofinishing lab 7218 Industrial launderers
First: ,~/ff., '~'7"~/L. ~'7'tg,t~t~ Second:
V. PRIOR PERMIT STATUS: Check yes or no to each question:
YES NO
[---] [~ 1. Did you file a PBR Notice of Intent to Operate (DTSC Form 8462) in 1992 for this location?'
[-"3 [~ 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim
[~ status for any of these treatment units?
1'"-] 3. Do you now have or have you ever held a state or federal full permit or interim status for any other
[~ hazardous waste activities at this location?
[-] 4. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you
are now notifying for at this location?
[] 5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator?
VI. PRIOR ENFORCEMENT HISTORY: Not required from conditionally exempt generators or commercial laundries.
Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or final
.. orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health.
enforcement agency?
(For the purposes of this form, a notice of violation does not constitute an order and need not be reported unless
it was nbt corrected and became a final order.)
If you answered Yes, .check this box and attach a listing of convictions, judgments, settlements, or orders a~d a copy
of the cover sheet from each document. (See the Instructions for more information)
VII. ATI'ACHMENTS: Attachments are not required from commercial laundries.
[~ 1. A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries.
~ 2. A unit specific notification form for each unit to be covered at this location.
DT$C 1772 (1/96) , 7 Page 2
EPA ID NUMBER ~/4,~ 00,.5,3ev/'~' Page 3 of ~'~
VIIL CERTIFICATIONS: This form must be signed by an authorized corporate officer or any other person in the.company who
has operational control and performx decision-making functions that govern operation of the facility (per Title 22, California
Code of Regulations (CCR) Section 66270.11). All three copies must have original signatures.
Waste Minimization I certify that I have a program in place to reduce the volume, quantity, and toxicity of waste generated to the
degree I have determined to be economically practicable and that I have selected the practicable method of treatment, storage, or
disposal currently available to me which minimizes the present and future threat to human health and the environment.
Tiered Permitting Certification I certify that the unit or units described in these documents meet the eligibility and operating
requirements of state statutes and regulations for the indicated permitting tier, including generator and secondary Containment
requirements. I understand that if any of the units operate under Permit by Rule or Conditional Authorization:, I will also provide
the required financial assurance for closure of the treatment unit by October 1, 1996.
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 directly responsible for gathering the information, the information
is, to the best of my knowledge and belief, true, accurate, and complete.
I am aware that there are substantial penalties for submitting false information, including the possibility of fines and imprisonment
for knowing violations.
Nme (Print or Type,) · Title
Signature' Date Signed
IX. REQUESTING A SHORTENED REVIEW PERIOD: Generators operating under CA aM/or CE are legally authorited
to operate 60 days after submitting a complete notification. DTSC may shorten the time period between notification and
authorization when the own_er or operator establishes good cause, ff you need to be authorized sOoner than the standard
60-day period, please check the box below and state the reason. Your authorization will be automatically effective on the
date your completed notification form is received by DT$C. (Use additional sheets, if necessary.)
F"] Reason:
OPERATING REQUIREMENTS:
Please note that generators treating hazardous waste onsibe are required to.comply with a number of operating requirements which
differ depending on the. tier(s). These operating requirements are set forth in the statutes and regulatior~, some of which are
referenced in the Tier-Specific Fact Sheets available from DTSC's regional and headquarters 'offices.
SUBMISSION PROCEDURES:
'All three forms must have original signatures, not photocopies. You must submit two copies of this completed notification by
certified mail, return receipt requested, to:
Department of Toxic Substances Control
Program Data Management Section, HQ-10
Attn: TP Notifications - Form 1772
400 P Street, 4th Floor, Room 4453 (walk in only)
P.O. Box 806
Sacramento, CA 95812-0806
You must also submit one copy of the notification and attachments to the local regulatory agency i.n your jurisdiction as listed in
Appendix 2 of the instruction materials. You must also retain a copy as part of your operating recordS-
PLEASE, DO NOT SEND YOUR FEE PAYMENT WIT~ THIS FORM..
DTSC 1772 (1/96) Page 3
EPA ID NUMBER ~AO00 OOO..O ~4g Page O~ of ~
CONDITIONALLY EXEMPT - SPECIFIED WASTEST~AMS
UNIT SPECIFIC NOTIFICATION
(pursuant to Health and Safety Code Section 25201.5(c))
The Tier-Specific Fact Sheets contain a summary of the operating requirements for this category. Please
review those requirements carefully before completing or submitting this notification package.
UNITNAME ,Z~6,~2)~'/'~,J/ ~A~ UNIT ID NUMBER ~---ffY/J~ ~ &
NUMBER OF TREATMENT DEVICES: __ Tank(s) ,~ Container(s)/Container Treatment Area(s)
Each unit must be clearly identified and labeled on the plot plan attached to Form 1772. Assign your own unique number Io each
unit. The number can be sequential (1, 2, $) or using any ~'stem you choose.
Enter the estimated monthly total volume of hazardous waste treated by this unit. This should be the maximum or highest amount
treated in any month. Indicate in the narrative (Section II) if your operatio~u have seasonal variations.
I. W~AMS AND TREATMENT PROCESSF~:
Estimated Monthly Total Volume Treated: .pounds and/or ,_~' 0 ~) gallons
YES NO !
[~ [~ Is the waste treated in this unit radioactive?
[--I [~ Is the waste treated in this unit a bio-hazardous/infectious/medical waste?
[--] [~ Is remotely generated hazardous waste (HSC 25110.10) treated in this unit?
The following are the eligible wastestreams and treatment processes. Please check all applicable boxes:
[-~ '1. Treating resins mixed or cured' in accordance with the manufacturer's instructions (including one-part and
pre-impregnated materials).
['-] 2. Treating containers of 110 gallons or less capacity that contained hazardous waste by rinsing or physical
processes, such as crushing, shredding, grinding} or puncturing.
~1 3. Drying special wastes, as classified by the department pursuant to Title 22, CCR, Section 66261.124, by
pressing or by passive or heat-aided evaporation to remove water.
[~] 4. Magnetic separation or screening to remove components from special waste, as classified by the department
pursuaflt to Title 22, CCR, Section 6626i..124'.
NOTE
5. NO AUTHORIZATION: IS NEEDED to neutralize acidic or alkaline {base) wastes from the regeneration of
ion exchange media used to demineralize water. (To be eligible for this exemption, this waste cannot contain
more than 10 percent acid or base by weight.) (Effective January 1, 1995).
6. NO AUTHORIZATION IS NEEDED to neutralize acidic or alkaline {base) wastes from the food processing
[~ industry. (Effective January 1, 1996).
7. Recovery of silver from photofinishing. The volume limit for conditional exemption is 500 gallons per
generator (at the same location) in any calendar month.
NOTE Silver recovery from .photofinishing is completely exempt from. authorization requirements if the quantity
treated is 10 gallons or less in any calendar month. Do not complete this form if you qualify .for this
exemption. (Retain documentation verifying your eligibility for this exemption, such as developer invoices.)
.. DTSC 1772B (1/96) ~. Page 10
EVA ID NUMBER' ene~ooo~,~ 'Page ~.~of ~
CONDITIONALLY EXEMPT - SPECIFIED WASTESTREAblS
UNIT SPECIFIC NOTIFICATION
(pursuant to Health and Safety Code Section 25201.5(c))
8. Gravity separation of the following, including the use of flocculants and demulsifiers if:
[~] a. The settling of solids from the waste where the resulting aqueous/liquid stream is not hazardous.
[] b. The separation of oil/water mixtures and separation sludges, if the average oil recovered per month is less
than 25 barrels (42 gallons per barrel). (NOTE: AB 483 (Ch 625, 1995) allows, certain used oil/water
separation under.new the CEL category. See Form 1772L and CEL Fact Sheet.)
[~] 9. Neutralizing acidic or alkaline (basic) material by a state certified laboratory, a laboratory operated by an
educational institution, or a laboratory which treats less tl4an one gallon of onsite generated hazardous waste
in any single batch. (To be eligible for conditional exemption, this waste cannot contain more than 10 percent
acid or base by weight.)
I--] 10. Hazardous waste treatment is carried out in quality control or quality assurance laboratory at a facility that
is not an offsite hazardous waste facility.
[--] 11. A wastestream and treatment technology combination certified by the Department pursuant to Section
25200.1.5 of the Health and Safety Code as appropriate for authorization under CESW.
Please enter certification number: (See Appendix 5)
[-'] 12. The treatment of formaldehyde or glutaraldehyde by a health care facility using a technology
combination certified by the Department pursuant to section 25200.1.5 of the Health and
Safety Code.
Please enter certification number:
NARRATIVE DESCRIPTIONS: Provide a'brief description of the specific waste treated and the treatment process used.
1. SPECIFIC WASTE TYPES TREATED:
2. TREATMENT PROCESS(ES) USED: 61LV[t~
IlL RESIDUAL MANAGEMENT: Che~ Yes or No to' each question as it applies to all residuals from t_his treatment unit.
YES NO
[--] 1. Do you discharge non-hazardous aqueous waste to a publicly owned treatment works (POTW)/sewer?
[--'] [~ 2. Do you discharge non-hazardous aqueous waste under an NPDES permit?
[~ [~ 3. Do you have your residual hazardous waste hauled offsite by a registered hazardous waste hauler?
If, you do, where is the waste sent? Check all that apply.
[~ a. Offsite recycling '
[--] b. Thermal treatment
[~] c. Disposal to land
---] d. Further treatment .
[--] [~/ 4. Do you dispose of non-hazardous solid waste residues at an offsite location?
['--] [-] 5. Other method of disposal. Specify:
DTSC 1772B (I/96) . ..~ .' Page 11
7''
EPA ID NUMBER (~4AaO'~O000",~/~? Page ~-t of"~
CONDITIONALLY EXEMPT - SPECIFIED WASTESTREAMS
UNIT SPECIFIC NOTIFICATION
(pursuant to Health and Safety Code Section 25201.5(c))
IV. BASIS FOR NOT NEEDING A FEDERAL PERMIT:
In order to demonstrate eligibility for one of the onsite treatment tiers, facilities are required to provide the basis for determining that
a hazardous waste permit is not required under the federal Resource Conservation and Recovery Act (RCRA) and the federal
regulations adopted under RCRA (Title 40, Code of Federal Regulations (CFR)).
Choose the reason(s) that describe the operation of your onsite treatment units:
[--] 1. The hazardous waste being treated is not a hazardous waste under federal law although it is regulated as a hazardous
waste under California state law.
[~ 2. The waste is treated in wastewater treatment units (tanks), as defined in 40 CFR Part 260.10, and discharged to a
publicly owned treatment works (POTW)/sewering agency or under an NPDES permit. 40 CFR 264. l(g)(6) and
40 CFR 270.2.
..
[~] 3. The waste is treated in elemehtary neutralization units, as defined in 40 CFR Part 260.10, and discharged to a
POTW/sewering .agency or under an NPDES permit. 40 CFR 264. l(g)(6) and 40 CFR 270.2.
[--] 4. The waste is treated in a totally enclosed treatment facility as def'med in 40 CFR Part 260.10; 40 CFR 264. l(g)(5).
[--"] 5. The company generates no more than 100 kg (approximately 27 gallons) of hazardous waste in a calendar month
and is eligible as a federal conditionally exempt small quantity generator. 40 CFR 260.10 and 40 CFR 261.5.
['-] 6. The waste is treated in an accumulation tank or container within 90 days for over 1000 kg/month generators and
180 or 270 days for generators of 100 to 1000 kg/month. 40 CFR 262.34, 40 CFR 270. l(c)(2)(i), and the Preamble
to the March 24, 1986 Federal Register.
[~ 7.. Recyclable materials are reclaimed to recover economically significant amounts of silver or other precious metals.
40 CFR 261.6(a)(2)(iv), 40 CFR 264.1(g)(2), and 40 CFR 266.70.
['-] 8. Empty, cont'ainer rinsing and/or treatment. 40 CFR 261.7.
['--] 9. Other: Specify:.
V. TRANSPORTABLE TREATMENT UNIT: Check Yes or No. Please refer to the Instructions for more information.
YES N[~
[--] Is this unit a Transportable Treatment Unit?
If you answered yes, you must also complete and attach Form 1772E to this page.
DTSC 1772B (1/96) Page 12
Plot Plan Attachment
1.3
State of California - California Enviroranental Protection Agency Department of Toxic Substances Control
Page 1 of
ONSITE HAZARDOUS WASTE TREATME NOTIFICATION FORM.
FACILITY SPECIFIC
NOTIFICATION [] Initial
Performing
For Use by Hazardous Waste Generators nded
Under Conditional Exemption and Conditional Author
Please refer to the attached Instructions before completing this form. You may notify forln~~y u, ~g this
notification form. DTSC 1772. You must attach a separate unit specific notification for~_~l%s?l'C}SuU~i~.lu~ ~tWa~l~O~I T~ ere are
different unit specific notification forms forfive of the categories and an additional notifica t ....... nt units
(TFU's). You only have to submit forms for the tier(s)/category(ies) that cover your unit(s). Discard or recycle the other unused
forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at
the 'Page ~ of__'. Put your EPA ID Number on each page. Please provide all of the information requested: all riel& must be
completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any
attachments.
The notification fees are assessed on the basis of the highest tier the notifier will operate under and will be collected by the State
Board of Equalization. DO NOT SEND YOUR FEE.PAYMENT WITH THIS NOTIFICATION FORM.
I. NOTIFICATION CATEGORIES
Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you
nutst.attach. Conditionally Exempt Small Quantity Treatment operators may not operate units under any other tier.
Number of units and .attached unit specific notifications for each tier reported.
A. Conditionally Exempt-Small Quantity Treatment (CESQT) D. ~ Permit by Rule (PBR)
B. S Conditionally Exempt-Specified WasteStream (CESgO E. CE--Commercial Laundry (CE-CL)
C. Conditionally Authorized (CA) F. Conditionally Exempt-Limited (CEL)
II.' GENERATOR IDENTIFICATION
EPA ID NUMBER CA'~ 0 0 ..__0 _0 ___O ~0'"~. _~0~ BOE NUMBER (if available) H__.HQ. '.
(DBA--Doing Business As)
PHYSICAL LOCATION a./0 ~/.~ [~'/'{S&°' /~V~A{/.I ~
CITY '~tq~/E;~3 g'/ETt..~ CA ZIP 9
COUNTY
CONTACT PERSON "~A:'/q ~ th/~4 ~..~0,~./~ PHONE NUMBER(~'0~')
(First Name) (Last Name)
MAILING ADDRESS, IF DIFFERENT:
COMPANY NAME Ou ceK
CITY '~taW/-/P, m STATE Me_., ZIP 2770,3-__
COUNTRY
(only complel~ if not USA)
CONTACT PERSON . Ttq IPtl I ~. ~)~[3Jf~ CC PHONE NUMBEh((~Ic
(Fir~ Name) (Last Name)
DTSC 1772 (1/96) Page
EPA ID NUMBER (~A/~I[oQD.5',~/~ 'Page 2 of.s~
III. RADIOACTIVE MATERIALS OR WASTE
YES N[~
--] Does the facility use, store or treat/'adioactive materials or radioactive waste?
IV. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE:
Use either one or two SIC codes (a four digit number) that best describe your company's products, services, or industrial activity.
Example: 7384 Photofinishing lab 7218 Industrial launderers
First: ,~/~ '~E'Y'~q/~ ~7'~'~ Second:
V. PRIOR PERMIT STATUS: Check yes or no to each question:
YES NO
[--'1 [~ 1. Did you file a PBR Notice of Intent to Operate (DTSC Form 8462) in 1992 for this location?'
[--] [~ 2. Do you now have or have you ever held a state or federal hazardous waste facilitY full permit or interim
j status for any of these treatment units?
[~] 3. Do you now have or have you ever held a state or federal full permit or interim status for any other
hazardous waste activities at this location?
[~] 4. HaVe you ever held.a variance issued by the Department of TOxic Substances Control for the treatment you
[~ are now notifying for at this location?
[-'] 5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator?
VI. PRIOR-ENFORCEMENT HISTORY: Not required from conditionally exempt generators or commercial laundries.
[--] Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or f'mal
orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health.
enforcement agency?
(For the purposes of this form, a notice of violation does not constitute an order and need not be reported unless
it was nlbt corrected and became a final order.)
[] If you answered Yes, .cheek this box and attach a listing of convictions, judgments, settlements, or orders ;md a copy
of the cover sheet from each document. (See the Instructions for more information)
VII. ATTACHMENTS: Attachments are not required from commercial laundries.
[~ 1. A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries.
[~ 2. A unit specific notification form for each unit to be covered at this location.
DTSC 1772. (1/96) .: ' '; Page 2
EPA ID NUMBER C/~ O O,~"d,~6Z~~' Page 3 of ~'~
VIII. CERTIFICATIONS: This form must be signed by an attthorized corporate officer or any other person in the-company who
has operational control and performs decision-making.functions that govern operation of the facility (per Title 22, California
Code of Regulations (CCR) Section 66270.1I). All three copies must have original signatures.
Waste Minimization I certify that I have a program in place to reduce the volume, quantity, and toxicity of waste generated to the
degree I have determined to be economically practicable and that I have selected the practicable method of treatment, storage, or
disposal currently available to me which minimizes the present and future threat to human health and the environment.
Tiered Permitting Certification I certify that the unit or units described in these documents meet the eligibility and operating
requirements of state statutes and regulations for the indicated permitting tier, including generator and secondary Containment
requirements. I understand that if any of the units operate under Permit by Rule or Conditional Authorization, I will also provide
the required financial assurance for closure of the treatment unit by October 1, 1996.
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 directly responsible for gathering the information, the information
is, to the best of my knowledge and belief, true, accurate, and complete.
I am aware that there are substantial penalties for submitting false information, including the possibility of fines and imprisonment
for knowing violations,
Name (Priht' or ,T0~e) ~ - /~ Title
Signatur8 ~ Date Signed
IX, REQUESTING A SHORTENED RE¥[EW PERIOD: Generators operating under CA and/or CF, are legally authorized
to operate 60 days after submitting a complete notification. DTSC ma~ shorten the time period between notification and
authorization when the own_er or operator establishes good ca~e. I. f you need to be authorized sooner than the ~tandard
60-day period, please check the box below and state the reason. Your authorization will be automatically effective on the
date your completed notification ~orm is received by DTSC. (Use additional sheets, if necessary.)
r-~ Reason:
OPERATING REQUIREMENTS:
Please note that generators treating hazardous waste onsi~e are required to.comply with a number of operating requirements which
differ depending on the~ tier(s). These operating requirements are set forth in the statutes and regulations, some of which are
referenced in the Tier-Specific Fact Sheets available from DTSC's regional and headquarters 'offices.
SUBMISSION PROCEDURES:
All three forms must have original signatures, not photocopies. You must submit two copies_, of this completed notification by
certified mail, return receipt requested, to:
Department of Toxic Substances Control
Program Data Management Section, HQ-10
Attn: TP Notifications- Form 1772
400 P Street, 4th Floor, Room 4453 (walk in only)
P.O. Box 806
Sacramento, CA 95812-0806
You must also submit one eot))' of the notification and attachments to the local regulatory agency i.n your jurisdiction as listed in
Appendix 2 of the instruction materials. You must also retain a copy as part of your operating recordS-
PLEASE, DO NOT SEND YOUR FEE PAYMENT WITH THIS FORM.
.. DTSC 1772 (1/96) Page 3
EPA ID NUMBER C~OO OOO,-ff, 3~ Page ~/of ~7
CONDITIONAI,LY EXEMPT - SPECIFIED WASTESTREAMS
UNIT SPECIFIC NOTIFICATION
(pursuant to Health and Safety Code Section 25201.5(c))
The Tier-Specific Fact Sheets contain a summary of the operating requirements for this category. Please
review those requirements carefully before completing or submitting this notification package.
NUMBER OF TREATMENT DEVICES: Tamk(s) ,~ Container(s)/Container Treatment Area(s)
Each unit must be clearly identified and labeled on the plot plan attached to Form 1772. Assign your own unique number to each
unit. The number can be sequential (1, 2, 3) or using any system you choose.
Enter the estimated monthly total volume of hazardous waste treated by this unit. This should be the maximum or highest amount
treated in any month. Indicate in the narrative (Section II) if your operations have seasonal variations.
I. WASTESTREAMS AND TREATMENT PROCESSES:
Estimated Monthly Total Volume Treated: pounds and/or ._~' 0 0 gallons
YES NO /
{~] [~ Is the waste treated in this unit radioactive?
[~] [~ Is the waste treated in this unit a bio-hazardous/infectious/medical waste?
D []~ Is remotely generated hazardous waste (HSC 25110.10) treated in this unit?
The following are the eligible wastestreams and treatment processes. Please check all applicable boxes:
[~ '1. Treating resins mixed or cured in accordance with the manufacturer's instructions (including one-part and
pre-impregnated materials).
['-] 2. Treating containers of 110 gallons or less capacity that contained hazardous waste by rinsing, ov physical
processes, such as crushing, shredding, grinding, or puncturing.
["-] 3. Drying special wastes, as classified by the department pursuant to Title 22, CCR, Section 66261.124, by
pressing or by passive or heat-aided evaporation to remove water.
[-'] 4. Magnetic separation or screening to remove components from special waste, as classified by .the department
pursuallt to Title 22, CCR, Section 6626i.124.
NOTE
5. NO AUTHORIZATION: IS NEEDED to neutralize acidic or alkaline (base) wastes from the regeneration of
ion exchange media used to'demineralize water. (To be eligible for this exemption, this waste cannot contain:.
more than 10 percent acid or base by weight.) (Effective January 1, 1995).
6. NO AUTHORIZATION IS NEEDED to neutralize acidic or alkaline (base) wastes from the food processing
[~ industry. (Effective January 1, 1996)'.
7. Recovery of silver from photofinishing. The volume limit for conditional' exemption is 500: gallons per
generator (at the same location) in any calendar month.
NOTE Silver recovery from .photofinishing is completely exempt from authorization requirements if the quantity
treated is 10 gallons or less in any calendar month. Do not complete this form if .you qualify .for this
exemption. (Retain documentation verifying your eligibility for this exemption, such as developer invoices0
.. DTSC 1772B (I/96) '. Page 10
EPA ID NUMBER' ~J~O00~3~ Page ~,~of ~
CONDITIONALLY EXEMPT - SPECIFIED WASTESTREAblS
UNIT SPECIFIC NOTIFICATION
(pursuant to Health and Safety Code Section 25201.5(c))
8. Gravity separation of the following, including the use of flocculants and demulsifiers if:
['-] a. The settling of solids from the waste where the resulting aqueous/liquid stream is not hazardous.
[-'] b. The separation of oil/water mixtures and separation sludges, if the average oil r~covered per month is less
than 25 barrels (42 gallons per barrel). (NOTE: AB 483 (Ch 625, 1995) allows certain used oil~water
separation under.new the CEL category. See Form 1772L and CEL Fact Sheet.)
[-'] 9. Neutralizing acidic or alkaline (basic) material by a state certified laboratory, a laboratory operated by an.
educational institution, or a laboratory which treats less than one gallon of onsite generated hazardous waste
in any single batch. (To be eligible for conditional exemption, this waste cannot contain more than 10 percent
acid or base by weight.)
I--] 10. Hazardous waste treatment is carried out in quality control or quality assurance laboratory at a facility that
is not an offsite hazardous waste facility.
['-] 'I1. A wastestream and treatment technology combination certified by the Department pursuant to Section
25200.1.5 of the Health and Safety Code as appropriate for authorization under CESW.
Please efiter certification number: (See Appendix 5)
[-] 12. The treatment of formaldehyde or glutaraldehyde by a health care facility using a technology
combination .certified by the Department pursuant to section 25200.1.5 of the Health and
Safety Code.
Please enter certification number:
II. NARRATIVE DESCRIPTIONS: Provide a brief description of the specific waste treated and the treatment process used.
1. SPECIFIC WASTE TYPES TREATED:
2. TREATMENT PROCESS(ES)USED: 8 i/.-~1 ~,t~
]III. RESIDUAL MANAGEMENT: Chec~ Yes or No to' each question as it applies to all residuals from t, his treatment unit.
YES NO
[--] 1. Do you discharge non-hazardous aqueous waste to a publicly owned treatment works (POTW)/sewer?
['-] [~ 2. Do you discharge non-hazardous aqueous waste under an NPDES permit?
[~ [-'] 3. Do you have your residual hazardous waste hauled offsite by a registered hazardous waste hauler?
If you do, where is the waste sent? Check all that apply.
[~ a. Offsite recycling
[--] b. Thermal treatment
[--] c. Disposal to land
'--] d. Further treatment .
[~] [~ 4. Do you dispose of non-hazardous solid waste residues at an offsite location?
[-] [~] 5. Other method of disposal. Specify:
DTSC 1772B (1/96) :~. Page 11
EPA ID NUMBER ~4,~ OO,.~,~qd'a0~ Page ~ of'~'
CONDITIONALLY EXEMP'F - SPECIFIED WASTESTREAMS
UNIT SPECIFIC NOTIFICA'T, ION~
(pursuant to Health and Safely Code Section, 25201'.5(c))
IV. BASIS FOR NOT NEEDING A FEDERAL PERMIT:
In order to demonstrate eligibility for one of the onsite treatment tiers, facilities are required to provide the basis for determining that
a hazardous waste permit is not required under the federal Resource Conservation and Recovery Act (RCRA) and the federal
regulations adopted under RCRA (Title 40, Code of Federal Regulations (CFR)).
Choose the reason(s) that describe the operation of your onsite treatment units:
[--] I. The hazardous waste being treated is not a hazardous waste under federal law although it is regulated as a hazardOus
waste under California state law.
[~tt 2. The waste is treated in wastewater treatment units (tanks), as defined in 40 CFR Part 260. I0, and discharged to a
publicly owned treatment works (POTW)/sewering agency or under an NPDES permit. 40 CFR 264. l(g)(6) and
40 CFR 270.2.
[--] 3. The waste is treated in .elemefitary neutralization units, as defined in 40 CFR Part 260. I0, and discharged to a
POTW/sewering ·agency or under an NPDES permit. 40 CFR 264.1(g)(6) and 40 CFR 270.2.
["-] 4. The waste is treated in a totally enclosed treatment facility as defined in 40 CFR Part 260.10; 40 CFR 264. l(g)(5).
[-'] 5. The company generates no more than i00 kg (approximately 27 gallons) of hazardous waste in a calendar month
and is eligible as a federal conditionally exempt small quantity generator. 40 CFR 260.10 and 40 CFR 261.5.
["-] 6. The waste is treated in an accumulation tank or container within 90 days for over 1000 kg/month generators and
180 or 270 days for generators of 100 to 1000 kg/month. 40 CFR 262.34, 40 CFR 270. l(c)(2)(i), and the Preamble
to the March 24, 1986 Federal Register.
[~ 7. Recyclable materials, are reclaimed to recover economically significant amounts of silver or other precious metals.
40 CFR 261.6(a)(2)(iv), 40 CFR 264. l(g)(2), and 40 CFR 266.70.
['-'] 8. Empty-container rinsing and/or treatment. 40 CFR 261.7.
['-] 9. Other: Specify:.
V. TRANSPORTABLE TREATMENT UNIT: Check Yes or No. Please refer to the Instructions for more information.
YES N~
[--'] Is this unit a Transportable Treatment Unit.'?
If you answered yes, you must also complete and attach Form 1772E to this page.
: DTSC 1772B (1/96) Page 12
Plot Plan Attachment
Storb: ~,.)~(~-~6~ c~ Store Number: '~.;L2.. Address: ~rC3 ~_.t~,~+~ ~ ~V~_ ,