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Contract - CR&R - 2012-09-24 State of California-California Environmental Protection Agency Department of Toxic Substances Control For DTSC Use Only PERMIT BY RULE NOTIFICATION FORM FOR PERMANENT HOUSEHOLD Region HAZARDOUS WASTE COLLECTION FACILITIES Please refer to the attached Instructions before completing this form. Initial Notification Revised Notification I 1 ! I. GENERAL INFORMATION ID NUMBER: CAL000378106 FACILITY NAME CR&R Household Hazardous Waste Facility FACILITY ADDRESS 7571 Lampson Avenue CITY Garden Grove CA ZIP 92841 - COUNTY Orange LOCATION The facility is located on the north side of (Description) the CR&R facility. It is not open to the public. (Latitude&Longitude) 33.781403, -118.000395 II. OPERATOR(PUBLIC AGENCY) NAME Costa Mesa Sanitary District ADDRESS 628 West 19th St CITY Costa Mesa STATE CA ZIP 92627- CONTACT PERSON Carroll Scott (Last Name) (First Name) TELEPHONE NUMBER (949)645-8400 III. CONTRACTOR INFORMATION(if applicable) NAME CR&R Incorporated ADDRESS 11292 Western Avenue CITY Stanton STATE CA ZIP 90680- CONTACT PERSON Ruffridge Dean (Last Name) (First Name) DTSC 1094B (Revised 11/08) Page 1 State of California-California Environmental Protection Agency Department of Toxic Substances Control TELEPHONE NUMBER (714 )826 _9049 PERMIT BY RULE NOTIFICATION FORM FOR PERMANENT HOUSEHOLD HAZARDOUS WASTE COLLECTION FACILITIES IV. THE FOLLOWING LOCAL AND/OR STATE PERMITS ARE REQUIRED FOR OPERATION OF THE PHHWCF: OBTAINED OBTAINED Hazardous waste Transporter YES© NO■Garden Grove planning approval YES NO Home-generated sharps consolidation YES NO ■ YES NO Hazardous Materials Disclosure YES NO 0 YES NO V. PROPERTY OWNERSHIP A. Is the property on which the PHHWCF is located owned by the operator? Yes ii No Z If not,a written agreement between the operator and the property owner is required. Property Owner's Name CR&R Incorporated - Phone(714 )826 _9049 Contact Person Dean Ruffridge VI, ACCEPTANCE AND MANAGEMENT OF SPECIFIC WASTE TYPES A. Will your facility accept wastes from conditionally exempt small quantity generators? Yes 0 No B. Will your facility accept waste from any of the following programs,facilities,or transporters? 1. Curbside household hazardous waste collection program? Yes © No 2. Door-to-door household hazardous waste collection program? Yes 0 No 3. Temporary household hazardous waste collection facility? Yes ■ No 4. Recycle-only household hazardous waste facility? Yes No 5. Mobile household hazardous waste collection facility? Yes No 6. Registered HW transporter carrying hazardous waste generated by a CESQG? Yes No 7. Registered HW transporter carrying waste from a loadcheck program? Yes No 8, Registered HW transporter carrying abandoned waste under public agency oversight? Yes X No 9. Other? Please explain Universal waste C. Does your facility categorically exclude any type of waste (e.g. explosives, infectious waste, compressed gas cylinders, etc.)? If so,please list those categories: Customers are notified that explosives, pharmaceuticals, and radloactives are not accepted. D. Will your facility consolidate any of the following wastes? X used oil I antifreeze water-based paint miscellaneous wastes oil-based paint n contaminated with solvents photographic solutions I I gasoline DTSC 1094B (Revised 11/48) Page 2 m NUMBER CAL0003781 06 igsolvents Elroofing tar caulking/patching compounds ❑ adhesives PERMIT BY RULE NOTIFICATION FORM FOR PERMANENT HOUSEHOLD HAZARDOUS WASTE COLLECTION FACILITIES VII. WASTE VOLUME A, Please indicate the approximate total volume of hazardous waste brought to the facility in an average month, Gallons or 3,000 Pounds B. What is the capacity of the container storage area(i.e.,drums,roll off bins,etc.)at the facility? 1. Individual storage area total capacity 1 ,000 gallons/pounds gallons 2. Individual storage area total capacity 1,000 gallons/pounds gallons 3. Individual storage area total capacity 500 gallons/pounds gallons 4. Individual storage area total capacity 220 gallons/pounds gallons 5. Individual storage area total capacity gallons/pounds 6, Individual storage area total capacity gallons/pounds What is the total number of tank storage areas? 1. Individual tank volume gallons. Waste stored 2, Individual tank volume gallons. Waste stored 3. Individual tank volume gallons. Waste stored 4. Individual tank volume gallons. Waste stored VIII. DAYS/HOURS OF OPERATION On the average,how many days each month is the facility open to accept wastes? 23 Days per month What are the hours of operation on the days that the facility accepts wastes from households and CESQGs? Example: Facility accepts CESQG wastes from 0900-1300 on the first Friday of each month and accepts household wastes Monday through Thursday of each week from 1000-1600 Household hazardous wastes are accepted from 8:00 am to 5:00 pm DTSC 1094B (Revised 11/08) Page 3 ID NUMBERCAL000378106 from CR&R collection vehicles. Management of wastes and maintenance activities may occur at any time. PERMIT BY RULE NOTIFICATION FORM FOR PERMANENT HOUSEHOLD HAZARDOUS WASTE COLLECTION FACILITIES IX. FACILITY DESCRIPTION: Please describe the facility in enough detail that a person not familiar with the facility will be able to understand the facility design. Include a description of the lighting,fencing,secondary containment for storage areas,etc. Received household hazardous wastes (HHW) are stored in two large lockers or outside the lockers on secondary containment pallets under cover (latex paint)or in a smaller locker. The Household Hazardous Waste Facility is located within the property contain a maintenance facility. The entire property compound is secured - : - : -• -: - -: : . '-g-en-eperetional hours with a security camera system and a security guard after hours. The entire property is paved with either asphalt or concrete. Wall mounted exterior fighting highfignts the area. Fire extinguishers are readily available. The vehicles used for collecting wastes are also stored within the compound. Collected wastes are removed from the collection vehicles and sorted by • •. .• - r r • r • - • . -• ' • • • , • .• .. •' •' - , , • other containers for storage. Maximum storage time for wastes is one year. When sufficient quantities are collected, a hazardous waste hauler is contacted to remove the wastes to approved facilities. • DTSC 1094E (Revised 11/08) Page 4 ID NUMBER CAL000378106 PERMIT BY RULE NOTIFICATION FORM FOR PERMANENT HOUSEHOLD HAZARDOUS WASTE COLLECTION FACILITIES X. REQUIRED ATTACHMENTS A. A plot plan of the facility B. IN Certification of financial responsibility for closure C. Copy of a written agreement between the property owner and facility operator allowing operation of the PHHWCF(if applicable) XI. OPERATOR CERTIFICATION(PUBLIC AGENCY) "I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and regulations for the permit by rule tier. I understand that I am required to provide financial assurance for the costs of closing this facility. I also understand that I am required to file a Phase I Environmental Assessment at a later date as part of the permit by rule application." "I certify under penalty of perjury under the laws of the State of California 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 significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations." rCc Geirfc.` 01')600 Q Name(Print or Type) Title / Cl . 24—►.2 Signature(Principal executive officer or ranking elected Date Signed official),CCR,Title 22,Section 66270.11. • DTSC 1094B (Revised 11/08) Page 5 Jun 30 2011 10:56AM W.E. Skinner Architect 7145466503 p. 1 r JI I I 1 111, I lVf Tip 111 .1..1-fTi1 i ( 1M1 { f I f f_f._I-f if> i I~` f f I L f .,.LL 1 ILI 1 II I I I ,i HHW Facility ! I . f I. I I , 1 i rn i . i )I i i g . : 1 i ' i Iy4 ..., i pi:aolg ` _:�. ...s ('H \ c -'' . • ' \ i € I f % 1. 1 I Ii I i 1 ; .,,--- . . 1 i , . , i Ili' I 1 , 41' - . .. • •4.41.L _. L P . Nil u, / LANP80N AVE. sia gggRe+acwoor.n,ax : T.... X 1 ' Bin I1 Bin I rcri CS? . 1 i j j, IVII = X co O r 6ftx6ft d HOUSEHOLD HAZARDOUS WASTE FACILITY BOUNDARY . 80 ft x 20 ft CR&R HOUSEHOLD HAZARDOUS WASTE FACILITY Map Legend Scale Facility Map 7571 LAMPSON AVENUE,GARDEN GROVE,CA 92841 Household Hazardous .. ! Hs�°�N« I I.NUL,�t, I Waste Facility Boundar 0 5 10 Rev.8/30/11 *SCALE 1:29 1 (SHEET 2OF2 k c''•a,.; Property Boundary Waf Wind Nearest t Garden Grove LOS ALAMITOS AAF (SLI] Windrose Piot [AU Year] ll,t/ Period of Record: 01 Nov 2010 - 01 Nov 2011 Number of Obs: 14791 NCalm: 41.0% Avg Speed: 4.2 mph 9.3 NW .. "' . .. . .. 15.4 NE .1.fi ,.. .7.8 • .,. 3.9 ' � ��' • W • ; ...... u�0 � o( E l;. • • N. '' - . ...' .. ' . .' . SW "+� ° .. SE 5 Wind Speed (mph] 2-5 :». _ 1 5-7 =7:1 7-10 10-15 F7-.7_'- 15-20 20+ State of California-California Environmental Protection Agency Department of Toxic Substances Control CERTIFICATE OF SELF - INSURANCE FINANCIAL ASSURANCE FOR COST OF CLOSURE TO BE USED BY PUBLIC AGENCIES OPERATING PERMANENT HOUSEHOLD HAZARDOUS WASTE COLLECTION FACILITIES (If additional space is needed, add attachments) Public Agency: Address : Costa Mesa Sanitary District 628 West 19th St. Costa Mesa CA 92627 Public Agency Official: Address : (if different from above) This Agreement demonstrates financial assurance for the following cost estimate(s) for the Permanent Household Hazardous Waste Collection Facility(ies) listed below: Facility Name Address ID Number Closure Cost CR&R Household 7571 Lampson Avenue CAL000378106 Estimate: Hazardous Waste Facility Date of Estimate: Closure Cost Estimate: Date of Adjustment: Closure Cost Estimate: Date of Adjustment: Closure Cost Estimate: Date of Adjustment: DTSC 1220 (revised 2196; modified for CUPA use 7/20/99) State of California-California Environmental Protection Agency Department of Toxic Substances Control CERTIFICATE OF SELF - INSURANC FINANCIAL ASSURANCE FOR COST OF CLOSURE CERTIFICATION: 1. Upon request by the Certified Unified Program Agency (CUPA) , the public agency agrees to furnish the CUPA any documents pertinent to this coverage. 2. Termination of this coverage will be effective only upon written notice, sent by certified mail, and only after the expiration of 60 days after a copy of such written notice is received by the CUPA as evidenced by the return receipts. 3. The public agency official named below hereby certifies that funds shall be available to close the facility listed named on this form whenever final closure occurs. The public agency also certifies that once final closure begins, the public agency shall be responsible for paying out funds, up to an amount equal to the full amount of the most recent closure cost estimate, upon direction from the CUPA, to such party(ies) as the CUPA specifies. Public Agency Official: Title: de/iectA.,( nct& - Typed or Printed name of Person Signing: Date: �C U Ca- cl- / 4 PRIVACY STATEMENT This information is requested by the Certified Unified Program Agency under Health and Safety Code Section 25245 in order to verify adequate financial assurance for household hazardous waste collection facilities. Completion of the form is mandatory. The consequence of not completing the form is denial of a permit to operate a household hazardous waste collection facility. Information may be provided to U.S. Environmental Protection Agency(EPA, State Attorney General, Air Resources Board, California Integrated Waste Management Board, Energy Resources Conservation and Development Commission, Water Resources Control Board, Department of Toxic Substances Control, and California Regional Water Quality Control Boards. For more information or access to your records, contact the Certified Unified Planning Agency. • DTSC 1220 (revised 2/96; modified for CtJPA use 7/20/99) KIH) .4 CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDlYYYY) 1112612011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED _ REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(Ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). �p-PRODUCER NAME•dY Solid Waste Insurance Managers $ fo Bxtl: i ,NO): 115 N.El Molino Ave ti ADDRE S: P.O.Box 7072 _ITAMER Pasadena,CA 91101 INSURERISI AFFORDING COVERAGE RAW S INSURED CR&R Incorporated INsuRER A:Great Divide Insurance Company 26224 _ Haulaway Storage Containers,Inc. INSURER B: 11292 Western Avenue mums: Stanton,CA 90880• INSURER D: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDDppULLC��cCEyyDggBYp PAID CLAIMS.ADM BR RR TYPE OPINSURANCB INSSR WVD POLICY NUMBER IMMID071'YY1') farDCDD LIMITS GENERAL UABIUTY EACH OCCURRENCE S 1,000,000 A X COMMERCIAL GENERAL LIABILITY X OLP01536654.10 9/3/2011 91312012 DAMADETO RENTED tVI PREMISEB(E9autsnce) ,S 300,000 I CLAIMS-MADE lid OCCUR I MED EXP(Any ens person) S 10,000 PERSONAL&ADVINJURY S 1,000,000 GENERAL AGGREGATE S 2,000,0001 — GEN'L AGGREGATE URMIITAPPUJE1SPER: PRODUCTS-COMP/OP AGG S 2,000,000 x POLICY I !dE8r I_ I LOC _ AUTOMOBILE LIABILITY X COMBINED SINGLE UNIT A X ANY AUTO BAP1536663.10 91312011 9/3/2012 BODILY $ 2,000,000 BODILYINJURY(Per perscn) S ALL OWNED AUTOS � _ SCHEDULED Amos BODILY INJURY(Per accident) $ PROPERTY DAMAGE HIRED AUTOS (Per acel ni) S — NON-OWNED AUTOS S _ S UMBRELLA LIAR OCCUR EACH OCCURRENCE S _ ,— EXCESS LIAR CLAIMS-MADE AGGREGATE _S _ DEDUCTIBLE S RETENTION I S WORKERS COMPENSATION I WCSTATU-I I01H. – AND EMPLOYERS'LIABIUTY Y f N TORY LIMITS ER ANY PROPRIETOWPARTNERIEXECUTIVE 0 E.L.EACH ACCIDENT $ OFFtCEWMBdBER EXCLUDED? N/A (Mandatory In NH) EL.DISEASE.EA EMPLOYEE S If v90 dascrtbe under DEEdRIPTION CF OPERATIONS below EL,DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 10i,Additional Remerke Schedule,If more space Is required) 30 day notice of cancellation/10 day for non payment of premium, CERTIFIED UNIFIED PROGRAM AGENCY,County of Orange,Health Care Agency,Environmental Health Hazardous Materials Management Section are Included as sddltlgnal insureds as cesnects to atachedendoisements, _ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CERTIFIED UNIFIED PROGRAM AGENCY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN County of Orange,Health Care Agency,Environmental Health ACCORDANCE WITH THE POLICY PROVISIONS, Hazardous Materials Management Section AUTHORIZED REPRESENTATIVE 1 Santa E.Ana,CA Suite 120 Santa Ana,CA 82706• i 6)1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009/09) The ACORD name and logo are registered marks of ACORD 1 1 POLICY NUMBER:GLP01536664.10 COMMERCIAL GENERAL LIABILITY CO 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR. ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Locations)Of Covered Opera tions CERTIFIED UNIFIED PROGRAM AGENCY Re:All Operations County of Orange,Health Care Agency,Environmental Health Hazardous Materials Management Section 1241 E.Dyer Road,Suite 120 Santa Ana,CA 92705 Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to This insurance does not apply to"bodily Injury'or include as an additional.insured the person(s) or "property damage"occurring after. organization(s) shown in the Schedule, but only . 1. All work, including materials, parts or equip- with respect to liability for"bodily Injury", "property damage" or "personal and advertising injury" on the eurnrohe t In connection service,e, mainte- caused, in whole or in part, by: on the protect (other than service, mainte- nance or repairs) to be performed by or on 1. Your acts or omissions;or behalf of the additional insured(s) at the lace- 2, The acts or omissions of those acting on your tion of the covered operations has been corn- behalf; pleted;or in the performance of your ongoing operations for 2. That portion of"your work" out of which the the additional insured(s) at the location(s) desig- Injury or damage arises has been put to its nated above, intended use by any person or organization B. With respect to the insurance afforded to these other than another contractor or subcontractor engaged in performing operations for a additional Insureds, the following additional exclu- slogs apply: principal as a part of the same projecs ect. CO 20 10 07 04 Copyright, ISO Properties, inc.,2004 Page 1 of 1 UNIFORM . ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO —�ADOPT]ONAL INSURED • is ti. i n. _ .. v -d L r; WHEN IRED RY CO.N TRA eti OR AGREEMENT .. ...._fir aL. .. ..... .i. .. .. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM—Policy Number: BAP1536653-10 Section II—Liability Coverage A.—Coverage,1. Who is an Insured, is amended to add; d. Any person or organization to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into,excluding contracts or agreements for professional services,which requires you to furnish Insurance to that person or organization of the type provided by this policy,but only with respect to liability arising out of your operations or premises owned by or rented to you. However,the insurance provided will not exceed the lesser of: 1. The coverage and/or limits of this policy;or 2. The coverage and/or limits required by said contract agreement. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. 0 2008 by Berkley Specialty Underwriting Managers,LLC,an affiliate of Nautilus Company and Great Divide Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office,Inc.,with Its permission ENV 2223 0408 Page 1 of 1 Agreement/MOU Points The Costa Mesa Sanitary District has contracted with CR&R, Inc. for the operation of a permanent Household Hazardous Waste Facility(HHWF). This program will be available for all residents of the City of Costa Mesa. The Costa Mesa Sanitary District agrees to be the hazardous waste generator on behalf of its residents. The Costa Mesa Sanitary District will also serve as the "Operator"of the HHWF for wastes collected under this program and CR&R will be the Contractor for the facility. The Costa Mesa Sanitary District will provide an authorized person to sign any documents needed for the permitting and operation of the HHWF. CR&R will locate the HHWF on its property located at 7571 Lampson Avenue, Garden Grove. CR&R will also obtain the permits and approvals needed for the HHWF. CR&R will also provide financial assurances as required for the facility operation. The Costa Mesa Sanitary District also authorizes a CR&R representative, as necessary,to complete and sign uniform hazardous water manifests and any other shipping papers used for the collected wastes in addition to completion of reports of wastes collected. CR&R will provide periodic reports to the Costa Mesa Sanitary District regarding facility operations. INSTRUCTIONS FOR COMPLETING PERMANENT HOUSEHOLD HAZARDOUS WASTE COLLECTION FACILITY PERMIT BY RULE NOTIFICATION . FOR PROPOSED FACILITIES FORM DTSC 109413 For use by public agencies proposing to operate a permanent household hazardous waste collection facility (PHI-IWCF). EACH SECTION OF THIS FORM MUST BE COMPLETED. INCOMPLETE FORMS WILL NOT BE PROCESSED. Please check at the top of the form whether this in an Initial or a revised notification. If this is a revision to an existing notification,place an asterisk(*)in the left margin next to the revised information. The notification must be revised whenever there is a significant change to the information required in this notification. Please enter the name of the facility and the facility identification number at the top of each page. I. GENERAL INFORMATION ID NUMBER: Enter your facility's 12-character California identification number. This number will begin with the letters "CAI-1", If you don't know your identification number or do not have an identification number,please contact the Department of Toxic Substances Control(DTSC)Manifest Unit at(916)324-1781. The Manifest Unit will provide you with your number or send you an application form(Notification of Regulated Waste Activity(EPA Form 8700-12)). FACILITY NAME; Enter the name of the permanent household hazardous waste collection facility, ADDRESS: Enter the physical address of the collection facility, LOCATION; Describe how to locate or get to the facility. If the facility lacks a street name,give the most accurate alternative geographic information(e.g,section number or quarter section number from county records or at Intersection of Rts.425 and 22). Also enter the latitude and longitude of the facility in degrees,minutes and seconds. You may use the map you provide for Item K to determine latitude and longitude, Latitude and longitude information is also available from Regional Offices of the U.S.Department of Interior, Geological Survey and from State Natural Resource Agencies. IL OPERATOR(PUBLIC AGENCY) NAME; • Enter the name of the public agency that will be the legal operator of the PHHWCF, ADDRESS; Enter the mailing address of the public agency. CONTACT PERSON: DTSC 1094B Instructions(Revised 11/08) Page 1 Enter the name of a contact person(last name first)in the public agency who is knowledgeable about the notification and the PHHWCF. TELEPHONE: Enter the area code and telephone number of the contact person, III, CONTRACTOR INFORMATION(IF APPLICABLE); Complete this item only if the operator has contracted with another entity(e.g.private contractor)to do the actual management of the PHHWCF. NAME; Enter the name of the contractor company. ADDRESS: Enter the mailing address of the contractor company. CONTACT PERSON: Enter the name of a contact person(last name first)in the contractor company who is knowledgeable about the operation of the PHHWCF, TELEPHONE NUMBER: Enter the telephone number of the contact person, IV. LOCAL AND STATE PERMITS REQUIRED FOR THE OPERATION OF FACILITY List all local and state permits required for the operation of the facility, If no permits are required,state "no(local/state)permits are required"on the form, Please indicate whether the required permits have been obtained, V. PROPERTY OWNERSHIP PROPERTY: Please indicate the legal ownership of the property on which the PHHWCF will be located. If applicable, include the property owner's name and telephone number. Note that if the property owner and the facility ; operator are different entitles,a written agreement must exist between the property owner and the PHHWCF operator allowing operation of the facility. VI. ACCEPTANCE OF AND MANAGEMENT OF SPECIFIC WASTE TYPES WASTE FROM CONDITIONALLY EXEMPT SMALL QUANTITY GENERATORS: Indicate whether the PHHWCF will accept wastes from conditionally exempt small quantity generators as defined by Health and Safety Code section 25218. NON-ACCEPTANCE OF CERTAIN WASTES: Please indicate if the PHHWCF will categorically exclude any certain types of waste, Use descriptive terms such as"compressed gas cylinders larger than 20 pounds". CONSOLIDATION OF RECYCLABLES: DTSC 1494E Instructions(Revised 11/09) Page 2 Please indicate which recyclable wastes will be consolidated at the PHHWCF. VII. WASTE VOLUME VOLUME COLLECTED: Please indicate the approximate total volume of hazardous wastes you estimate will be brought to the P1-IHIWCF in an average month. Please indicate this figure in either g lions,or pounds,. STORAGE CAPACITY: Please indicate the total capacity of each separate container storage area and specify gallons or pounds. A storage area would usually be a bermed area with an impervious base or some other type of secondary containment. Then for individual tanks,please indicate the maximum capacity of the tank and the type of waste which is stored in that tank. VIII. DAYS AND HOURS OF OPERATION Enter the average number of days per month during which the PHl-IWCF will accept.wastes. Indicate also the hours the PHHWCF will be in operation on the days waste is being accepted. Show the hours using a 24-hour clock(for example: 8 am should be shown as 0800 and 1 pm should be shown as 1300), IX. FACILITY DESCRIPTION Please provide a detailed description of the physical components of the facility in enough detail that a person not familiar with the facility would be able to enter the facility and be able to understand the facility design. Include fencing,gates,traffic flow,waste removal area,waste sorting areas,and waste storage areas,etc. X. REQUIRED ATTACHMENTS A, FACILITY PLOT PLAN: Each facility must include a drawing showing the general layout of the facility. This drawing should be approximately to scale and fit on an 8W by 11"sheet of paper. This drawing should show the following: 1, . Map scale and date, 2. The property boundaries of the facility. 3. Wind rose orientation, 4, The areas occupied by all storage and treatment units that will be used during operation of the PHHWCF. 5. The name and location of each operation area(Example: used oil storage tank, consolidation area,etc.). 6. The approximate dimensions of the property boundaries and each storage and treatment area. 7. Security provisions(fencing,gates,etc). 8. Internal roads;on and off site traffic flow, B. CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR CLOSURE; Attach certification required by Title 22,CCR,section 67450.30(b). DISC 1094B Instructions(Revised 11/08) Page 3 C. WRITTEN AGREEMENT BETWEEN PROPERTY OWNER AND FACILITY OPERATOR: Please submit a signed agreement by the property owner acknowledging and allowing the operation of the facility if the property owner is different from the legal operator(Public Agency). XI. OPERATOR CERTIFICATION This section must be completed by a chief executive officer or elected official of the public agency operating the PHHWCF,as specified in Title 22,CCR,section 66270.11. Each copy submitted must have an original signature. INSTRUCTIONS FOR SUBMITTAL OF NOTIFICATION After completing the form,retain one copy for your records. Additionally,the owner of a PHHWCF shall submit,in person or by certified mail with return receipt requested,a DTSC Form 1094E(11/08)with original signature to CUPA or authorized agency. Submit another copy with original signature to the Department address given below: Department of Toxic Substances Control Consumer Products Section Office of Pollution Prevention and Green Technology P.O. Box 806, I Ith floor Sacramento,California 95812-0806 DTSC 1094B Instructions(Revised 11/08) Page 4