HomeMy WebLinkAboutBUSINESS PLAN (4) Hazardous Materials/Hazardous Waste Unified Permit
.~ CONDITIONS OF..-PERMIT ON REVERSE SIDE
~ H-~ous ~als P~n
~ Unde~mu~ Storage ~ H~Ous ~s
Permit ID ~:: 015~00~02005 ~ Risk Man~e~t P~mm
VONS ~2033 a ,.~ou. w.m o~ T~
LOCATION: 4500 COFFEE RD
OFFICE OF ENVIRONMENTAL SER VICES' "
1715 Chester Ave., 3rd Floor ,' Appmved by:
. v(.~ Ralpl{Hucy, DI'~L~ j Issue Date
Bakersfield, CA 93301
Voice (661) 326-3979 '
FAX (661) 326-0576 ',Expi!'a,..tionDate: ',June 30. 2003
. ~'- .~ i,":.~::.5,,; -' ?"?:..:~> ' ",.'-:.*'- .......
Fire Evacuation Procedures Earthquake Fire Extinfluishers
- C~l[ 9-1-1. ' Remain calm Duck and Cover. 7'0 opera e a f re ext gu sher
- Remain calm and identify yourself. · Your signal to evacuate is either the fire elam], Stay clear of tall objects end windows P - Pull the [)in
· Give the Iocat or and nature of the emergency ar] announcement over the public address Coca the initial shocks have subsided, A - Aim at the base of tile fire
- Warn others in the immediate area system or a fellow employee, stay under cover. S - Squeeze the trigger handle
- Use an extinguisher oniy if it is a small fire. - Uf~losk doo~ as you leave your area. Assist the injured. S - Sweep from side ta side
· Follow evacuation instructions. · Close ali doors as you exit. Check for hazards. ~BC~SLE~tD_r.-rCG,~d,j?~IJJ~.S. reoardless_Ef_~qeir size·
- If smoke is present, stay Iow', crav,4 oil your' - Move in an orderly feahiea toward the stairs Evacuate the building only if instructed to do so
hands and knees to the nearest exit. ~nd/or exits of the building. Use stairs only.
· Walk to the nearest emergency exit· Close all Go [o relocation area· Be prepared for afterstlocks. Medical
doom as you go. Do not use eievators - Wait there for fudher instructions. · Stay calm and gather the infom~ation.
· C~-'..il 9-%1.
· Identify yourself and give your location.
· Descdbe the emergency situation.
~---~--~ Advise fellow employees of the emergency and
e. sk for assistance.
· Assist the victim to the degree that you are train,sd
®
(~ FROZEN FOOD R.R.
WAREHOUSE Hazardous Material
[~ · Notify your super¢isor.
F~ ~ I I . identify materials irwolved, if kno
J · If required, evacuate the immediate area and keep others ouL
PRODUCE MEAT SEAFOOD DAIRY BOX BREAK Assist those ~¢,Io cannot ieave oil their own.
· E~ ROOM · Refrsin ~rom smoking, eating, ddnking and applying cosmetics·
BOX ~ [~ ] I
/ Civil Disorder
· Notify your supervisor.
SER'
C~E / . Range!ri withie the buiid~r,g.
DE J - Do not become a spectator.
- Do nothing to antagonize the demonstrators.
~ ' ~...~ ¢~,~¢~, · Affair fudher insLructions from yo ..... pervisor.
KIDS FLORAL PHARMACY
CLUB I CHECKSTANDS I I 'B°mbD° eot Threat panic.
BAK
RY [ R.R. - Notify your supen,'isor.
~ [~ - Your supervisor ,Mil notify the secudty
--~ ~ WELLS department and the police.
CUSTOMER IMGRI I I I FARGO - Await instructions.
L_~ E~ SERVICE ~__
I~J LeRends:
· ~N -- S4 EVACUATION MAP [iiiiii!iii!i!R~-~?~(~Ni!iiiiiiiiiii[ Primary Emergency Exits
(Not TO Scale) :::::::::::::::::::::::::::::::::::::::::::7: Fire Extinguishers
3 Water Main / Sprinkler Riser
Meter Shut Off Valve
Gas
VONS 2033
4500 COFFEE RD. Relocation Area
BAKERSFIELD, CA 93308
SEPT. 98
q"~e Vons Gom. pani~, Inc.
c/o Safeway, Inc. CITY OFBAKERSFIELD
M/S 6516 ~ ~ Box 2o57
Phoenix, AZ 85038-9096
CHARGE DATE .. I ON~,":~ ' REr.-NUMBER DUE DATE TOTAL AMOUNT
~/O1/OO :B-EOI~NN'INO BgL-ANCE:,.. , . O0
SSO01 6/01/00 C¢~ '¢'STATE.,... ~ ., SURCHARGE.. [0. O0
FOR QUESTIONS OR 'TO YOUR ACCOUNT PLEASE
CALL THE NUMBER AT THE TOP OF THIS 8TATEHENT.
~,,===~T OVER 30 OVER 60 OVER 90
i2~9~-.~0 ..........
DUE DATE' 7/03/00 PAYMENT DUE: 1~0.00
TOTAL DUE: $120.00
CITY OF BAKERSFIELD FIRE DEPARTMENT
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301
FACILITY NAME L/~xf'3. ~ ~D'~'3 INSPECTION DATE q ~,/C50
ADDRESS 47~'~.3 Co~a-~x.~ 5?.0 PHONE NO.
FACILITY CONTACT C/-6z~c~ C'--'s~, ~-,.tx- BUSINESS ID NO. 15.210-
INSPECTION TIME NUMBER OF EMPLOYEES ~'-
Section 1: Business Plan and Inventory Program
~l Routine ~[.Combined I~l Joint Agency I~] Multi-Agency ~] Complaint [~l Re-inspection
OPERATION C V COMMENTS
Appropriate permit on hand
Business plan contact information accurate
Visible address
Correct occupancy
Verification of inventory materials
Verification of quantities ,/3,,~E54'3 ~'~6~ '00r~,,,26
Verification
of
location
Proper segregation of material 0
Verification of MSDS availability
Verification of Haz Mat training
Verification of abatement supplies and procedures
Emergency procedures adequate
Containers properly labeled
Housekeeping
Fire Protection
Site Diagram Adequate & On Hand
C=Compliance V=Violation
Any hazardous waste on site.: ~:Yes ~] No /---3~S
Questions regarding this inspection? Please call us at (661) 326-3979 itc Responsible Party
White- Env. Svcs. Yellow- Station Copy Pink- Business Copy Inspector: (-~
CITY OF BAKERSFIELD FIRE DEPARTMENT
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301
FACILITY NAME LJ~.~ INSPECTION DATE 4-/(t ;~...)
Section 5: Itazardous Waste Tier Permit Treatment Program
[] Routine ~2ombined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection
Onsite Treatment Unit Tier: Unit number & name:
[] PBR [] CA [] CESW [] CESQT [21CEL [2i CECL
OPERATION C V COMMENTS
Ali hazardous wastes treated are generated onsite
Onsite treatment notification forms available and complete
Onsite treatment unit tier and/or count is correct on form
Unit number is correct on notification tbrm
Number of tanks or containers is correct on form
Treatment monthly volume is correct on form
Waste identification 8: treatment is correct on form
Complies with residual management requirements
Properly closed a treatment unit
Complies with tank and containment certification //
Developed and maintains a written inspection log
Meets pretreatment standards for waste discharge /
Developed and maintains a Closure Plan on site IPBRI
Developed and maintains a Waste Analysis Plan and Waste Analysis
Records [PBRI
Maintains Training Records on site IPBR]
Obtained local permits for treatment operations [PBRI
Identifies and labels Treatment Units [PBRI
C=C°mpliance V=Vi°lati°n ~e
Inspector: ~Jt
Office of Environmental Services (805) 326-3979 sponsible Party
CA=Conditionally authorized CESW=Conditionally exempt specified wastestream
CECL=Conditionally exempt commercial laundry CESQT=Conditionally exempt small quantity treatment
CEL=Conditionally exempt limited PBR=Permit by rule
White - Env. Svcs. Pink - Business Copy
'CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakers~f~ld, C~A (805) 326-3979
MATERgALS
~,z~umovs ISWSTO~~
' FACILITY DESCRIPTION VOT~ 6
CHECK IF BUSINESS IS A FARM [ ]
FACILITY NAME ~D{'~ ~'~ ,ir-- "~) .~'~
SITE ADDRESS ~
CITY ~ STATE C~ ZIP 9 ,'~C) ~
NA~,,~ o,~,~usI~ss ~~'~<.
SIC CODE_~__~_~_ DUN&BRADSTREETNUMBER~)O~ JSD- coO~Y '
EMERGENCY CONTACTS
1
5) W~ C~S~CA~ON (3~t ~ ~ D~ F~ 80~) USE CODE
6) P~SIC~STA~ ~5d[ ] LiqMd[ ] ~] ~[ ] ~[ ] W~
7) ~O~ ~~ AT FAC~ ~ OF ~~ 8) STOOGE
9) ~: L~ CO~~
~y ~ ~~ 3 )
6) P~SIC~STA~ · ~hd[ ] Liq~d[] ~[~] ~[ I ~[ ] W~
7) ~o~ ~ ~ AT ~AC~ ~ O~ ~~ S) Sm~OS
~mD~y~t I~t~0 L~[ ]~[ ]~K] a)C~
~ ~o~t c) T~
10)L~A~ON
P~ N~e & TiflLofiui~ Com~Rm~ve Si~
Page of
Business Name A~
'i~on ' CHE~C~ DES~ON
l) INVENTORY STATU [ ] Revision [ ] I~l~on { ] Ch~ck if chemical is a NON Trad~ S~r~t [ ] Trade S~a~t
2) Common Name: ~l= 3} DOT # (optional) =,
Ch(m~ical Name: ~ AHM [ ] CAS #
4 ) Physical & Health PHYSICAL HEALTH
Hazard Categories Fire [ ] R~:ti~ [ i Sudden Rekas~ of Pr~s,mre [ ] lmm'~tin),· Health (Acute) [ ] Delay~ Health (Chronic)
5) WASTE CLA~SIHCATION (3=di~it exxi~ fix)m DI~ Form 8022) USE CODE
' }
6).PHYSICALSTATI~ SOlidi ] Liqui( ] Oas[ ]. Pure[ ] Mixture[ ] Waste[ ] Radioa~ive[ ]
?) AMOUNT AND ~ AI' FACILITY \ UNrrS OF MEASURE S) STORAOE CODES
Annual.amount . ~,. ~) T~rature
Largest Siz~ Contmm.
# D~y~ on $it~ Citr, l~ Which Months: AIl Year, I, F, M, A, M, $, ~, A, S, O, N, D
9) MIXTURE: List! COMPONENT CAS# % WT AHM
ch~mi~ compon~ or 2) [
any AHM componeats 3) [
0)LOCATION
~)n,r~ro~¥$T^~ s:~{ ]addition{ ]~'~sion£ ]~etion[ ] C"ne~ffc~nic~isaNONTrad~Sen~[ ]TmieSecret[ ]
2) Co~on N~e: '~ 3) ~T t
' [ ~ ' ~DmF ~ USE CODE
5) W~ C~CA~ON ~ (~t ~ )
.... . ' -- ......
7) ~O~ ~ ~ AT FAC~ . [ ~ )
~mD~omt ' ,/~[ l~[ ]~[ ] a) Con~ ~_
~ ~t~ _ _ 'X c) T~~ ' _
~ Da. ~ Sim C~le~~: ~ Y~, l, F, ~ ~ ~ ~, ~, ~ S, O, N, D
9)~: Lm/ CO~~''~ ....... C~ %~
· e ~ mo~ ~. l) . " ' [ ]
ch~ ~m~ ~ 2) " [ ]
~y ~ ~m~m 3) [ ].
IO)L~A~OH ' -
~lieve ~. m~ ~~ ~' ~ ~ ~ ~pl~.. ..
P~ N~e & Tide of A~o~ Comfy ~m~ve Si~ D~
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (805) 326-3979
INSTRUCTIONS: ,,
1. To avoid further action, return this form within 30 days of receipt.'
2. TYPEA?~ ANSWERS IN ENGLISH. . :
3. Answer the questions below for,the busine~ as a whole. '
4. , Be as b.-iofaad concis~ as possiblo.~ " : ' -.
SECTION l' BUSINESS IDENTIFICATION DATA
~~O ~D~SS: ~
C~: ~ STAm:~ ~:~' ,'PHO~:(6
D~ ~ B~S~T ~~ 00- I~- ~O~ SIC CODE:gq
P~Y AC~: ~~
J
SECTION 2: ~R~CY NOT~CA~ON
CO~ACT ~ BUS. PHO~ 24 ~ PHO~
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 3: TRAININ~
~v~s~ o~ ~o~.s: i C)-~'
~A~ SALTY D^TA S~TS OS ~: ~ ~~
B~F S~Y OF ~O PROOf:
SECTION 4: EXEMPTION REOUEST
I CERTIFY UNDER PENALTy.. OF PERJURY THAT MY BUSINEss IS EXEMFr FROM
THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH
& SAFETY CODE" FOR THE FOLLOWING REASONS:
'- ' WE.DO NOT HANDLE HAZARDOus MATERIALS..
WE DO HANDLE HAZARDOUS' MATERIALS, BUT THE QUAN'rlTIES AT
NO TIME EXCEED 'THE MINIMUM I~.P0RTINO QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION
I, ' ' CERTIFY THAT THE ABOVE
INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WIlL BE
USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH
AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500
ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PFAUUKY.
SIGNATURE ' ._ ~ITLE 4-'- - "/ 'DATE
2
ILs-7.ARDOUS MATERIALS MANAGEMENT PLAN
Section 8 - Utility Shut-Offs:
List loCations of shut offs u~ing compass points and known or obvious landmarks. It you
have a lock box, list its loCation also. _
Section 9 - Private Fire Pr0tection/W~ter Av~il~ility:
A) Private Fire Protection: Describe on-site ire protection for your business or-
facility unit, including sprinklers, lire extinguishers, alarm systems and priva~
response teams.
B) Water Availability (Fire Hydrant): Give the location of the closest water supply
or fir¢.hyd.-"~nt to be used by the Fire Department in case of an _~c~nerffency.
NOTE
If your business covers either a large geographical area or consists of several fa 'alities
(separate manufacturing or storage areas), Sections 6, 7, 8, and 9 of the ~) must be
completed for each facility. You must also complete a separate inventory and facility
diagram for each facility unit or building.
3
IL~,ZARDOUS MATERIAL~ MANAGEMENT PLAN
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES
A... AGENCY, NOTIFICATION PROCEDURES:
B. EMPLOYEE NOTIFICATION AND EVACUATION:
C. 'pUBLIc EVACUATION:
D. EMERGENCY MEDICAL PLAN:
3
I~&RDOUSMATERIAL$ MANAGEMENT PLAN
SECTION 7: MITIGATION. PREVENTION AND ABATEMENT PLAN
A. RELEASE PREVENTION STEPS:
B. RELEASE CONTAINMENT AND/OR MINIMIZATION:
C. CT.PAN-UP PROCEDURES:
SECTION 8; UTIL~ SHUT-OFFS _('LOCATION OF SHUT-OFFS AT YOUR FACILITY') '
SaTtm,~OASa'~.O~'A,',m: Locct~d nnr-t~-e.o,.5-P OF
~EC~C~:
L~K BOX:' ~S~O ~ ~8, L~A~O~:
SEC~ON 9: P~A~ F~ ~RO~C~ON~A~R AV~~
A. PRIVATE FIRE PROTECTION:
B. WATER AVArLABILITY (FIRE HYDRANT):
4
#33 VONS GROCERY
CLINICS
ALTERNATE pRIMARY
Bakersfield Occupational Med Mercy Medi Center-Truxton
4580 California Ave 2215 Truxton Ave
Bakersfield CA 93309 Bakersfield CA 93302
(805) 327-4411 (805) 663-6100
M-Sun 8AM-9PM M-Sun 10AM-10PM
Spanish SPanish
HOSPITAL
Bakersfield Memorial Hospital
420 34th St
Bakersfield CA 93301
(805) 327-1792
Open 24-Hours
Spanish
Should you become injured on the job; 1. Report your injury to your supervisor 2. Obtain a written referral from
your supervisor.
NOTE: The hospital emergency room should be used only when after hour medical care is necessary. ~
and or follow up medical care is to be done the followln~_ morning at your assigned clinic.
EXCEPTION: Probable Cause drug testing is permitted in hospital emergency room if probable cause incident
occurs after hours.
VONS33
r State of California - California Envirom~ Protection Agency Department of Toxic
Substances
Control
Page I of
ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM
FACILITY SPECIFIC NOTIFICATION " ~" [] Initial
For Use by Hazardous Waste Generators Performing Tredt,ment
fi. [] Amended
Under Conditional Exemption and Conditional Author~z~uon:,
and by Permit By Rule Facilities
Please refer to the attached Instructions before completing this form. You may notify for more than on.e permitting tier. by using this
notification form, DTSC 1772. You must attach a separate unit specific notification fornt for each unit at this location. There are
different unit specific notification forms furtive of the categories and an additional notification form for transportable treatment units
(TTU's). You only have to submit forms for the tier(s)/category(ies) that cover your unit(s). Discard or recycle the other unused
fortH. 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 prov]de al! 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 (PBR)
B. ~ 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~ O 0 00 _L_,.5' 5/ _~/~.~. BOE NUMBER (if available) H__HQ_
FACILITY NAME V'0AJ~, ~ ,~9~.~
(DBA--Doing Business As)
PHYSICAL LOCATION /'~ ~'0 0 G0,a'~'~ /~ 0,6 b
CITY ~ O~',,t',.q' ,;"'/~Z.-~ CA ZIP ~,~O,
COUNTY /ff. ~'~ CO.
CONTACT PERSON . ~ tor~.,~;Ct-vO~ {.~ ~L.~[-ad PHONE NUMBER(O,,~&)'4",~I
(First Name) (Last Name)
MAILING ADDRESS, IF DIFFERENT:
COMPANY NAME O Ui~ L..~--. g
CItY ~]~/~/d~ STATE AJ ~ ZIP ,,~ '/70...~
COUNTRY
(only complete if not USA)
CONTACT PERSON ,_'J-~rlm 1-~ -~P~I$/C'/L-C_ PHONE NUMBERt~/q ) ~",,~_,~..
(First Name) (Last Name)
DTSC 1772 (1/96) Page 1
EPA ID NUMBER 00 / ~"~g/.~ Page 2 of ~
III. 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: '7,~5/ -P4407~o~/~t3~t/xtc_, 'a~g Second:
V. PRIOR PERMIT STATUS: Check yes or no to each question:
YES NO
~-1 [~f 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
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.
YES NO
['-] [~ Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or fin~l
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 not corrected and became a final order.)
[-"1 If you answered Yes, .check this box and attach a listing of convictions, judgments, settlements, or orders and a copy
of the cover sheet from each document. (See the Instructions for more information)
VH. ATTACH34ENTS: Attachments are not required from commercial..laundrie5.
1. A plot plgn/map detailing[ tl/~' location(Z) 6.f'th~e covere~l.'untt(g) ih relation to.the facility boundaries.
2. A unit specifi.,c, n0tificat!on form for each unit to be covered at .thi~ loc~ion.
DTSC 1772 (1/96) Page 2
EPA ID NUMBER ~lt~ooo l D-"///E_ Page 3 of__~
VIII. CERTIFICATIONS: This form must be signed by an authorized 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. II). 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 (Print or - Yitl~' /J- /O~t'C.-'e '
Signature Date Signed
IX. REQUESTING A SHORTENED REVIEW PERIOD: Generators operating under CA and/or CE are legally authorized
to operate 60 days after submitting a complete notification. DTSC may shorten the time period between notification and
author&ation when the owner or operator establishes good cause. If 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 DTSC. (Use additional sheets, if necessary.)
YES
---] Reasoll: ~
OPERATING REQUIREMENTS:
Please note that generators treating hazardous Waste onsite 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:
Ali three forms must have or(~inal 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 cop.v of the notification and attachments to the local regulatory agency in your jurisdiction as listed in
Appendix 2 of the instruction materials. You must also retain a copy as part of your operating record.
PLEASE, DO NOT SEND YOUR FEE PAYMENT WITH THIS FORM.
DTSC 1772 (1/96) Page 3
CONDITIONALLY EXEMPT - SPECIFIED WASTESTREAMS
UNIT SPECIFIC NOTIFICATION
(pursuant to Health and Safety Code Section 25201.5(c))
The Tier-Specific Fact Sheets contain a summary 0[' the operating requirements for this category. Please
review those requirements carefully bel~ore completing or submitting this notification package.
NUMBER OF TREATMENT DEVICES: Tamk(s) ,~' Container(s)/Container Treatment Area(s)
Each unit must be dearly identified and labeled o$~ 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 mo_rimum or highest amoum
treated in any month. Indicate in the narrative (Section II) if your operations have seasonal variations.
I. WASTESTREAMS AND TREA~ PROCESSES:
Estimated Monthly Total Volume Treated: pounds and/or / 0 ~ gallons
YES NO
[--] [~, Is the waste treated in this unit radioactive7
[~] [~ Is the waste treated in this unit a bio-hazardous/infectious/medical waste?
~ [~ Is remotely generated hazardous waste (HSC 25110.10) treated in this unit7
The following are the eligible wastestreams a~xl treatment processes. Please check all applicable boxes: '.
1-'-1 '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.
[-'] 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 screeniug to remove components from special waste, as. classified by the department
pursuatlt t6 Title 22, CCR, Section 6626i.124. -
NOTE
5. NO AUTHORIZATION IS NEEDED to neutralize acidic or alkaline (base) wastes from the rege~eration 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 docum6ntation verifying your eligibility for this exemption, such as developer invoices.)
DTSC 1772B (1/96) .... ~/c ~ Page 10
· <: .,~','.
EPA ID NUMBER' ~~~_~_.~ Page
CONDITIONALLY EXEMPT- SPECIFIED WASTESTREAMS
UNIT SFECIFIC NOTIFICATION
(pursuant to He~Jth and Safety Code Section 25201.$(c))
8. Gravity separation of the following, inclnding the use of Hocculants 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). (grOTE: 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,)
[--1 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.
[~l '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:
II. NAllRA. TIVE DESCRIPTIONS: Provide a brief description of the specific waste treated and the treatment process Used.
1. SPECIFIC WASTE TYPES TREATED: ,.~/LV~,~
III. RESIDUAL MANAGEMENT: Checl~ Yes or No to' each question as it applies to all residuals from thi_xs 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
['--1 c. Disposal to land
--'1 d. Further treatment . ..
['-] ~ 4. Do you dispose of non-hazardous solid waste residues at an offsite location? .'
~ ["-I .5. Other method of disposal. Specify:.
DTSC.: 1772B (I/96) .: .,,-~.~ ~:;.TPage 11
· , . ~:-
EPA ID NUMBER ~.-~-~_l~k~'~,g Page ~ 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 recmon(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 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. l(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 264.1(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. Emptyl.,cont'ainer rinsing and/or treatment. 40 CFR 261.7.
[-'1 9. Other: Specify:.
V. TRANSPORTABLE TREATMENT UNIT: Check Yes or No. Please refer to the Instructions for more information.
YES NO /
['"'1 [~ 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
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