HomeMy WebLinkAboutHAZ-BUSINESS PLAN 2/5/1998
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State of California' California E~viromnental Protection Agency
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Department of Toxic Substances Control
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ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM
DEPARTMENT OF TOXleG'-Initial
STANCES CONTROL ended
FACILITY SPECIFIC NOTIFICATION
For Use by Hazardous Waste Generators Performin
. Under Conditional Exemption and Conditional Auth
and by Permit By Rule Facilities
Please rèfer to the attached Instructions before completing this form. You may notify
notification form. DTSC 1772. You must attach a separate unit specific notification rm or eac 41 4tA is oca on. ere are
different unit specific notification forms for five of the categories and an additional notification orm or transporta e re ment units
(ITU's). You only have to submit forms for the tier(s)/category(ies) that cover your unites). 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 fields must be
completed except those that state 'if different' or 'if available'. Please type the information provided on this fonn 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.
B. -L Conditionally Exempt-Specified Wastestream (CESW)
C. Conditionally Authorized (CA)
E.
F.
Permit by Rule (PBR)
CEo-Commercial Laundry (CE-CL)
Conditionally Exempt-Limited (CEL)
ll. ' GENERATOR IDENTIFICATION
EPA ID NUMBER CA~ J2 Q Q 12.Q:J~ 7 L
BOE NUMBER (if available) H_HQ_ ~ _ _ _ _ __
COUNTY
jJAU;~~e:IlI..s· -::#=- ~3 £.ø 0
J.jj{) 0 WHITE. LAAle
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CA
ZIPq.330~ -
FACILITY NAME
(DBA-Doing Business As)
PHYSICAL LOCA nON
CITY
CONTACT PERSON
ü"flmes
(First Name)
7'"uÆÆ¡
(Last Name)
foS
PHONE NUMBER<->~- Oa~l
MAILING ADDRESS, IF DIFFERENT:
STREET
Q\..tAl.E.~ J /JJe..
40.20 ð'f'/ H/lU,o ~E:£I( "DR. Ôrc.. 2/1
COMPANY NAME
CITY
Vl.(~HAM
STATE IJe. ZIP 2,7703-_
COUNTRY
CONTACT PERSON
(only complete if not USA)
. 1",4 am ~
(First Name)
DR/SKIL£;
(Last Name)
PHONE NUMBER(.iéL) ¿"I¥'4 - J (Q fJY
DTSC 1772 (1/96)
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EPA ID NUMBER e..AR .'00.5 3, I
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ill. RADIOACTIVE MATERIALS OR WASTE
YES
o
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Does the facility use, store or treat radioactive materials or radioactive waste?
IV. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE:
Example.;
Use either one or two SIC codes (a four digit number) that best describe your company's products, services, or industrial activity.
7218 Industrial launderers
7384 Photo{inishin1! lab
First: 59/.2 '1.e1"AI¿ 8-rD.é'e:.
Second: 7.3i-l 'P/lDTOPRÕ(!£ ßSIHG LJ4;(3
V. PRIOR PERMIT STATUS: Check yes or no to each question:
YES
o Did you file a PBR Notice of Intent to Operate (DTSC Form 8462) in 1992 for this location?·
o 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?
o 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?
o Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you
are now notifÿing for at this location?
o Has this location ever been irispected by the state or any local agency as a hazardous waste generator?
~ 1.
~ 2.
fl- 3.
ri 4.
ri 5.
VI. PRIOR, ENFORCEMENT mSTORY: Not required from conditionally exempt generators or commercial laundries.
YES
o
;
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 nðt corrected and became a final order.) ,
o If you answered Yes, .check this box and attach a listing of convictions, judgments, settlements, or orders and a copy
of the cover shèet from each document. (See the Instructions for more infonnation)
VII. A1TACHMENTS: Attachments are not required from commercial laundries.
ci
[if
1.
2.
A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries.
A unit specific notification form for each unit to be covered at this location.
, .
DTSC 1772 (1196)
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EPA ID NUMBER CARoOOQI)5c37/
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VßI. CERTIF1CA TIONS: 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 ofthefacility (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 Permittine 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 I, 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.
MA NAf::ÞF:R. OF P,.IOTO F-,NISJ..J "oJt;
Title
?~S-:7f
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
authorization when the ow~er or operator establishes good cause. !f 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
o Reason:
OPERATING REQUIREMENTS:
Please note that generators treating hazardous waste onsÚe 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-s'pecific Fact Sheets available from DTSC's regional and headquarters offices.
SUBMISSION PROCEDURES:
All three forms must have orieinal 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-IO
AUn: 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 il) 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 TIllS FORM.
DTSC 1772 (1/96)
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EPA ID NUMBER c.I4R0000063'11
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CONDITIONALLY EXEl\1PT - SPECIFIED W ASTESTREAMS
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 requirement" carefully before completing or submitting this notification package.
UNIT ID NUMBER cm X ...5 Û
UNIT NAl'vIE 116fìÞ&m Y ¿JR¿¿
,£ Container(s)/Container Treatment A~ea(s)
NUMBER OF TREATMENT DEVICES:
_ Tan.l(s)
Each unit must be clearly identified and labeled on the plot plan attached to Fonn 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 I1) if your operatio1!S have seasonal variatio1!S.
I. W ASTESTREAMS AND TREATMENT PROCESSES:
YES
D
D
D
D 1.
0 2.
0 3.
D 4.
NOTE
5.
~
NOTE
Estimated Monthly Total Volume Treated:
pounds and/or ,;¡ 0 0 gallons
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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 25110.10) treated in this unit?
The following are the eligible wastestreams and treatment processes. Please check all applicable boxes:
Treating resins mixed Or cured in accordance with the manufacturer's instructions (including one-part and
pre-impregnated materials).
Treating containers of 110 gallons or less capacity that contained ha,zardous waste by rinsing or physical
processes, such as crushing, shredding, grinding, or puncturing.
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.
Magnetic separation or screening to remove components from special waste, as classified by the department
pursuant to Title 22, CCR, Section 66261.124.
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).
Recovery of silver from photofinishing. The volume limit for conditional exemption is 500 gallons per
generator (at the same location) in any calendar month.
7.
Silver recovery fromphotofinishing 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, su¡:h as developer invoices.)
DTSC 1772B (1/96)
Page 10
8.
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EPA ID NUMBER e,q,.f.005<~'71
12.
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CONDITIONALLY EXEMPT - SPECIFIED W ASTESTREAMS
UNIT SPECIFIC NOTIFICATION
(pursuant to Health and Safety Code Section 25201.5(c»
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 eEL Fact Sheet.)
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.)
Hazardous waste treatment is carried out in quality control or quality assurance laboratory at a facility that
is not an offsite hazardous waste facility.
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)
The treatment of fonnaldehyde 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:
ll. NARRATIVE DESCRIPTIONS: Provide a'brief description of the specific waste treated and the treatment process used.
ID.
YES
&'
D
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1. SPECIFIC WASTE TYPES TREATED: SILVER -l3éAfIlJb, w¡::,&-rE. SOl..-u-1'IoAl,s
~ËIJ£~A-ï'£D /!,V OJJ~-lIo£lR f'1/i)1'o/,RtX!£$S/A/t:, L..Aé.
2. TREATMENT PROCESS(ES) USED: 8/LVEj?, tee (I.DV~,e"ý UA/rr {..I-r.¡L-/i!;¡IIÝ!I
Æ M.ETALL'~ ~€.PLA~E.M..E.AlT M£íR¡D6.g8 /# 5f:;R/(5~ .
RESIDUAL MANAGEMENT: Check Yes or No to' each question as it applies to all residuals from this treatment unit.
NO
D
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,
1. Do you di!ìcharge non-hazardous aqueous waste to a publicly owned treatment works (POTW)/sewer?
2. Do you discharge non-hazardous aqueous waste under an NPDES pennit?
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,
eM a. . Offsite recycling .
[Y(
D
D b. Thermal treatment
D c. Disposal to land
0 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
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EPA.ID NUMBER r.A.e~O OS..3'1/
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Page Lt of7
CONDITIONALLY EXEMPT - SPECIFIED WASTESTREAMS
UNIT SPECIFIC NOTIFICA nON
(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 (l'itle 40, Code of Federal Regulations (CFR)).
Choose the reason(s) that describe the operation of your onsite treatment units:
D
&' 2.
D 3.
D 4.
D 5.
0 6.
~
D
D
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 260.10, and discharged to a
publicly owned treatment works (POTW)/sewering agency or under an NPDES permit. 40 CFR 264.1(g)(6) and
40 CFR 270.2.
The waste is treated in elementary neutralization units, as defIned in 40 CFR Part 260.10, and discharged to a
POTW/seweringagency or under an NPDES permit. 40 CrR 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 260.10; 40 CFR 264.1(g)(5).
The company generates no more than 100 kg (approxirpately 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 270 days for generators of 100 to 1000 kg/month. 40 CFR 262.34, 40 CFR 270. 1 (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 CPR 261.6(a)(2)(iv), 40 CFR 264. 1 (g)(2) , and 40 CFR 266.70.
8.
Empt:rcontainer 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
D
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Is this unit a Transportable Treatment Unit?
If you answered yes, you must also complete and attach Fonn 1772E to this page.
DTSC 1772B (1/96)
Page 12
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