HomeMy WebLinkAboutHAZARDOUS WASTEState of California - California Environmental Protection Agency
Department of Toxic Substances Control
.Page I of'7
ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM,
[~]; nitlal
· " FACILITY SPECIFIC NOTIFICATION:
ForUse by Hazardous Waste Generators Performinl
Under Conditional Exemption and C°nditional Auth(
and by permit By Rule Facilitie~
Tr :e~--~... ~B CES controL : nended
C__.~._ .:: ' _.; ....~i,i~er b) ~s~ng this
brm tor eacn ~,,,~-~- , ~ere are
. --~ ,,~,t units
5catton fo~ Jor trur~p~ ......... nent
DisCard Or re~cle the other unused
Please refer to the aitached Instructions before completing this f°rm' You may notify.
notification form, DTSC 177Z You must attach a separate unit specific notification.
different unit SPecific notification forms for five of the categories and an additional n.ot
OTU's). You only have to submit forrns for the tier(s)/category(ies) that cover your unit(s);
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 fields must be
completed except those that state 'if different' or 'if availableV 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 undet and will be collected by the State
Board of Equalization. DO NOT SEND YOUR FEE-PAYMENT WITH THISNOTIFICATION FORM;
I. NOTIFICATION CATEGORIES ' . '
~ Indicate the number Of units you operate in each tier. This will also be the '~umber of unit specific notificationforms 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)
~ ' CE._Commercial Laundry (CE-CL)
B. i conditionally Exempt-Specified Wastestream (CF_3W) E.
~ F. Conditionally Exempt-Limited (CEL)
n.- mEN riFICATION
EpA ID NUMBER _0Q.._O O=Q' C) iL'7
FACILITY NAME
(DBA--Doing Business As)
PHYSICAL LOCATION
BOE NUMBER (if available): H__HQ~_.
CITY
COUNTY
CONTACT PEilSON
~First Name)i
MAILING ADDRESS, IF DIFFERENT:
CA
(Last Name)
zi :9 3
pHoNE NUMBER(gO~)
COMPANY NAME
STREET
C~TY
cOUNTRY
CONTACT pERSON
STATE A,/~-~. ZIp 2770a:~
~only compieie if not= USA).,
(First Nanie)
DTSC 1772 0/96)
mo
YES
EPA ID NUMBER'(~,£ J~O0
'Page 2 of~
RADiOACT~VE MATERIALS OR WASTE
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:
First:
7384. Photofinishing lab
Second:
7218 Industrial launderers
&oq' To//aT'ot oeag.&a/x/c .
V. PRIOR PERMIT STATUS: Check yes or no to each question:
YES NO
[] 2.
· Did you file a PBR Notice of Intent to Operate (DTSC Form 8462) in 1992 for this location?' --
Do you now have or have you ever held a State or federal hazardous waste facility full permit or interim
staius for any of these treatment units?
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?
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?
Has this location ever been insPected by the state or any local agency as a hazardous waste generator?
PRIOR-ENFORCEMENT HISTORY: Not, required from conditionally exempt ge. nerators or commercial laundries.
YES
Within the last thre~ years, has this facility been the subject of any cohvictions, 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 ~ order and need not be reported unless'
it was nbt cofrected and' became a final order.).
If you answered Yes, icheek this box and attach a listing of con~tictions, judgments, settlements, or orders aiid. a copy
'of the cover sheet from each document.. (See the Instructions for more information)'
ATTACHMENTS: Attachments are not required from commercial' laundries.
1'. A plot plan/map detailing the location(s) of the covered unit(s) in re!ation to the facility boundaries.
2. A unit specific notification form for each unit to be covered at this iocakion..
Page 2
DTSC 1772 (1/96)
EPA ID NUMBER
Page 3 of ~
VIII. CERTIFICATIONS: This form must be signed by an attthorized corporate officer or any qther person in the .company who
has op~erationai control and performs 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 } certify that I llave a program in place to reduce the volum¢, quantity, and tgxicity of waste generated to the
degree I have determined io be'economically practicable and that.I, have selected: the pra. cticable 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 certi~ 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, ! 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 ag, d~ belief,~ true:, accurate, and: complete.
1 am aware that there are substantial penalties for submitting false information, including the possibility of fines and imprisonment
for knowing violations.
Name (Print or Type)
Signature
Ti'tle
Date Signed
IXe
REQUESTING A SHORTENED REVIEW PERIOD: Generators operating under CA and/or CE are legally authorized
to operate 6'0 days after submitting a. complete notification. DTSC may shorten the time period between notification and
authorization when the owner or operator establishes good cause. I. f you need to be authorized sOoner than the standard
60-day period, please chemic 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.).
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 t~e Tier-~pecific Fact Sheets available from DTSC's regional and headquarters 'offices:
SUBMISSION PROCEDURES:
~' Alt 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, t0
Attm TP Notifications- Form 1772
400p 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
Appendix'2 of. the instrucii°ri~.materials. You must also retain a t:opy as pm of your operatin~ record(: .
PLEASE, DO NOT SEND YOUR FEE PAYMENT WITH THIS FORM..
DTSC 1772 (1/96) Page 3
EVA ID NUMBER O...~_~k
Page 4 of_~
CONDITIONALLY E MPT - 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: ~ 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 to each
unit. The number can be sequential (I, 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
Indicate in the narrative (section II) if your operations have seasonal, variations.
WnSTVS n S eROC ss s:
Estimated Monthly Total Volume Treated: pounds and/or ,~ 0 D gallons
treated· in any-month.
L
Is the waste treated in this. unit radioactive?.
Is the waste treated in this unit a bio.hazardous/infectious/medical waste?
Is remotely generated hazardous waste (HSC 25110. i0) treated in this unit?
yES NO
The following are the eligible wastestreams and treatment processes.
,,
NOTE
5.
NOTE
Please check all applicable boxes:
Treating reSins mixed or cured, in. accordance with the manufacturer's instructions (including one-part and
pre-impregnafed mat6rials)~ ' ~
· Treating containers of 110 gallons or leSs capacity that contained ha.zard0us waste by rinsing, or'phYsieai~
proceSseS, such as crushing,: shredding, grinding, or puncturing.
'Drying speeial; wastes, as classified by the department pursuant to Title 22, CCR, Section 6626L124, by
pressi~ng or by passive or heat-aided evaporation to remove water.·
Magnetic separation or screening~ to remove components from special waste, as classified by -the department
Pu~Suafit t'0 '~itle. 22, CCR; SectiOn 6626L124. '
NO AUTHORIZATION is'NEEDED- to neutralize acidic or alkaline (base) wastes from tlie regeneration o~
ion exchange· m6di~ Used:to demi'neralize water. (To be eligible for this exemption, this Waste cannot contain
more than 10 percent acid or base' by Weight.) (Effective January 1, 1995).
NO AUTHORIZATION' IS NEEDED_ to neUtralize acidic or alkaline (base) wastes from the fOod· processing
~ndustrY. (Effective January I, 1~96)'.
Recovery o[ sliver from photofinishing. The vol'nme, limit for conditional exemption is 500 gallons: per
generator (a~ 'tfi~~ Same location), in any calendar month.·
SilVer re,covery, from· photofinishing is completely exempt fi'om: authorization, requirements if the quantity:
treated; is: 10i g~l?ns~' .o.r~: !~s in.any.' calendar month. Do: not complete this form if you qualify .~or this
exempfi°m. (Retain d°cum~ntati0n verifying yOur eligibility for thiS exemption~ ~u'ch as develOper invoiceS:)
DT$C 1772B (1/96)
Page I0
EP.~ ID NUMBER.
Page ~,~of ~
CONDITIONALLY EXEMPt, - SPECIFIED wASTESTREAMs
uNIT spECIFIC NOTI.:F!CA':FIONi.
(pursuant to Health and, Safety Code section
8. ' Gravity separation of the following, including the use of flocculants and~ deraUlsifiers if:.
a:. The settling of solids from the Waste where ~h9 resulting aqueous/liquid stream is not hazardous.
b, The separation of oil/water mixtures and Separation~ sl'ud'ges~, if th9 average oil recovered' pe~: month is less
than 25 barrels (42 gallons per barrel).. (NOTE: ,~ 483' (Ch }525, 1995) allows certain Used oil~water
.- separation under.new the CEL category. See Form 1772Land CEL Fact Sheet.)
9; Neutralizing acidic or alkaline (basic) material by a state certified, laboratovy, a:.laborat0ry operated by an
edUcational institution, or a laboratory which, treats less than, 0ne'gall0n of onsite generated hazardous waste
ir{ any single batch. (To be eligible.f0r conditi0nallexemption, thiS.Waste cannot contain:more than 10 percent
acid or base by weight.)
10,-~ Hazardous waste treatment is carried out in quality control or quality assurance Iaboratory 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.
sPECIFIC WASTE TYPES TREATEp:_,~/LVE~ -~Efl~.lld{_~ -l~lf~'f~ SOI.,U'T/OZ/~
2. TREATMENT PROCESS(ES) usED:_ 81/--VE~ /~
RESIDUAL tVIANAGE/VIENT: Checl~ Yes or No tol each question, as it. applies to all residUals from thi. s. treatment unit.
NO , -
~-ql · 1. Do you di'scharge non-hazardous aqueous waste tO a publicly owned .treatment works (POTW)/sewet?
2. Do you. discharge non-hazardous agueous waste under an NPDES permit?
~] 3. D0 you have your residual hazardous waste hauled offsite by a registered hazardous, waste hauler?
If you do, where is the waste sent? CMck all that apply.
~' a. Offsite recycling '
[~: b. Thermal treatment
[~]. c. Disposal to land
--] d. Fttrther treatment .
4. Do you dispose of non-hazardoUs solid: waste residues at an offsite location?
5'.. Othe~ method: of disposal:. SpecifY:. . ... ' : ..
DTSC 1772B (1/96~. '.
-. ?
Page
EPA ID NUMBER
CO,Nq)ITIONALLY EXEMYI? - SPECIFIED: WP~STEST'REAMS; '
UN}T sPECIFIC NOTIFICATION "
(pursuant to H'ealth~ 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 fO~ determining that'
a hazardous waste permit is not required under 'the federal Resource Conservati°n and' Re~over~ Act' (RcRA),'and? the'federal',
regulatibns' 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.
The waste is treated in wastewater treatment units (tanks):, as defined~ in, 40 CFR, part 260..!0} and! discharged~ to a
publicly owned treatment works (POTW)/sewering agency or under an NPDES permit 40 CFR 264~.~(g)(6)3 andi
40 CFR 270.2. :..
The waste is treated in elemehtary neutralizati6n uni(s, as defined xn. 40 CFR Part 260.10,.,an~ dtscha~ged to a
POTW/sewering agency or under an, NPDES permit. 40 CFR 264:'. 1 (g)(6). and,'40 CFR, 270,,2:."
The waste is treated in a totally enclosed treatment facility as defined in 40 cFR Part 260.10i
o
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.
The waste is treated in an accumulation: tank or Container within. 90 days for over 1000 kg/month generators and'
180 or 279 days for generators of 100 to 1000 kg/month. 40' CFR. 262.34, 40 CFR 270.1(c)(2)0), ant} the Preamble
to the March 24, 1986 Federal Register. ~
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. i(g)(2), and' 40 CFR 266.70..
[-'] 8. Empty-container rinsing and/Or treatment. 40 CFR 26L7.
9-. Other: Specify:=
YES'
TRANSPORTABLE TREATMENT UNIT: Check Yes or No~ Please refer to the InstructiOns f°r more information.
Is this unit a Transportable Treatment Unit?
If you answered yes, you must also complete and attach. Form 1772E to this page~
· Page 12
DTSC 1772B (1/96) . "
Plot Plan Attachment
Store: Numbe~:. 32.cf z./_
Address:
0