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Annual Permit Review - CR&R - 2014-02-02 February 2, 2014 Scott Carroll General Manager Costa Mesa Sanitary District 628 W. 19th Street Costa Mesa, CA 92627-2716 RE: Annual Permit Review and Certification of Financial Assurance for Signature Dear Mr. Carroll: Attached is the completed Annual Permit Renewal Package and Certification of Financial Assurance for the Household Hazardous Waste Collection Facility. Orange County Environmental Health currently administers the Household Hazardous Waste (HHW) program and recently was assigned the responsibility for this hazardous materials disclosure program. The required forms do not directly accommodate the unique nature of HHW programs. California requires local government agencies to sponsor the HHW programs and CR&R is your contractor for this service. CR&R representatives have verified these responses with the Orange County Certified Unified Program Agency(CUPA) including the requirement that jurisdiction's are designated as the "Business Owner" for these forms. In order to complete these forms, a City representative needs to sign and date these forms in the places designated on the attached note. Similar to the original Permit-by-Rule,the City representative signing these documents must be by either a ranking elected official, principal executive officer or senior executive officer, or by a representative duly authorized in writing. The completed forms are to be e- mailed by March 3, 2014 to arashidi@ochca.com or mailed to: Orange County Environmental Health Attn:James Hendron 1241 E. Dyer Road, Suite 120 Santa Ana, CA 92705 Please retain a copy for your records and provide CR&R with a copy. Thank you for the opportunity for CR&R to provide this valuable service to your residents. Please contact me with any questions. Sincerely, Dean Ruffridge Senior Vice President CR&R INCORPORATED 11292 WESTERN AVE. P.O.BOX 125 STANTON,CA 90680 800.826.9677 714.826.9049 714.890.6347 Fax CRRWASTESERVICES.COM recycled paper efit °-od OC CUPA UNIFIED PROGRAM CONSOLIDATED FORM 92 1241 E.Dyer Rd Ste.120 „ Santa Ana,CA 92705 FACILITY INFORMATION• Tel:(714)433-6000 o9tIFOR��¢ Fax:(714)754-1768 BUSINESS ACTIVITIES www;.o.c c.waal nfo.c.o.m Pagelof5 I. FACILITY IDENTIFICATION FACILITY ID# I EPA ID#(Hazardous Waste Only) 2 (Agency Use Only) 3 0 CAH000378106 BUSINESS NAME(Same as Facility Name of DBA-Doing Business As) Costa Mesa Sanitary District Household Hazardous Waste Facility 3 BUSINESS SITE ADDRESS 7571 Lampson Avenue 03 BUSINESS SITE CITY Garden Grove 104 CA ZIP CODE 92841 105 II.ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, please submit the Business Owner/Olerator Identification page. Does your facility If Yes,please complete these pages of the UPCF A. HAZARDOUS MATERIALS Have on site(for any purpose)at any one time,hazardous materials at or above 55 gallons for liquids,500 pounds for solids,or 200 cubic feet for compressed HAZARDOUS MATERIALS gases(include liquids in ASTs and UST5);or the applicable Federal threshold ❑■ YES ❑ NO 4 INVENTORY—CHEMICAL quantity for an extremely hazardous substance specified in 40 CFR Part 355, DESCRIPTION Appendix A or B; or handle radiological materials in quantities for which an emergency plan is required pursuant to 10 CFR Parts 30,40 or 70? B. REGULATED SUBSTANCES Have Regulated Substances stored onsite in quantities greater than the threshold quantities established by the California Accidental Release ❑ YES 0 NO 4. Coordinate with your local agency prevention Program(CaIARP)? responsible for CaIARP. C. UNDERGROUND STORAGE TANKS(USTs) UST FACILITY(Formerly SWRCB Form A) Own or operate underground storage tanks? ❑ YES 0 NO 5 UST TANK(one page per tank)(Formerly Form B) D. ABOVE GROUND PETROLEUM STORAGE Own or operate ASTs above these thresholds: Store greater than 1,320 gallons of petroleum products (new or used) in ❑ YES El NO 8 NO FORM REQUIRED TO CUPAs aboveground tanks or containers. E. HAZARDOUS WASTE Generate hazardous waste? YES ❑ 1:1 NO 9 EPA ID NUMBER—provide at the top of ■ this page Recycle more than 100 kg/month of excluded or exempted recyclable materials RECYCLABLE MATERIALS REPORT (per HSC 25143.2)? ❑ YES It NO to (one per recycler) Treat hazardous waste on-site? ❑ YES III NO t t ON-SITE HAZARDOUS WASTE TREATMENT—FACILITY ON-SITE HAZARDOUS WASTE TREATMENT—UNIT (one page per unit) Treatment subject to financial assurance requirements(for Permit by Rule and Conditional Authorization)? El YES ❑ NO 12 CERTIFICATION OF FINANCIAL ASSURANCE Consolidate hazardous waste generated at a remote site? ❑ YES NO t3 REMOTE WASTE/CONSOLIDATION SITE ANNUAL NOTIFICATION Need to report the closure/removal of a tank that was classified as hazardous YES HAZARDOUS WASTE TANK waste and cleaned on-site? ❑ NO 14 CLOSURE CERTIFICATION Generate in any single calendar month 1,000 kilograms(kg)(2,200 pounds)or Obtain federal EPA ID Number,file more of federal RCRA hazardous waste, or generate in any single calendar Biennial Report(EPA Form 8700- month,or accumulate at any time, 1 kg(2.2 pounds)of RCRA acute hazardous ❑ YES IN NO 14a 13A/B),and satisfy requirements for waste;or generate or accumulate at any time more than 100 kg(220 pounds)of RCRA Large Quantity Generator. spill cleanup materials contaminated with RCRA acute hazardous waste. Household Hazardous Waste(HHW)Collection site? I] YES ❑ NO 14b See CUPA for required forms. F. LOCAL REQUIREMENTS is (You may also be required to provide additional information by your CUPA or local agency.) UPCF Rev.(12/2007) OC UPCF 2/08#I23 Distribution: White-OC CUPA Yellow-Participating Agency Pink-Notifying Business/ ,<<c'5 o,, OC CUPA Unified Program Consolidated Form 1241 E.Dyer Rd Ste.120 V J11\ dM Santa Ana,CA 92705 FACILITY INFORMATION Tel:(714)433-6000 9PF,~T Fax:(714)754-1768 BUSINESS OWNER/OPERATOR IDENTIFICATION www:occunainfo.corn Page 2of_5_ I. IDENTIFICATION FACILITY 1D# 3 0 I BEGINNING DATE 100 ENDING DATE 101 J revv-MM-dd vvvv-MM-dd BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 BUSINESS PHONE 102 Costa Mesa Sanitary District Household Hazardous Waste Facility BUSINESS SITE ADDRESS 103 BUSINESS FAX 102a 7571 Lampson Avenue BUSINESS SITE CITY 104 ZIP CODE 105 COUNTY 108 Garden Grove CA 92841 ORANGE DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a BUSINESS MAILING ADDRESS 1083 11292 Western Avenue BUSINESS MAILING CITY 108b STATE 108c ZIP CODE 1084 Stanton CA 90680 BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 CR&R, Incorporated (949)425-2531 II. BUSINESS OWNER OWNER NAME 111 OWNER PHONE 112 Costa Mesa Sanitary District (949) 645-8400 OWNER MAILING ADDRESS 113 628 W. 19th Street OWNER MAILING CITY 114 STATE 115 ZIP CODE 116 Costa Mesa CA 92627-2716 III. ENVIRONMENTAL CONTACT CONTACT NAME 117 CONTACT PHONE 118 David Latham (714) 826-9049 CONTACT MAILING ADDRESS 119 CONTACT EMAIL I I9a 11292 Western Avenue DavidL @crrmail.com CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 Stanton CA 90180 -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- NAME 123 NAME 128 Ron Drost John Boyle TITLE 124 TITLE 129 HHW Facility Supervisor Risk Manager BUSINESS PHONE 125 BUSINESS PHONE 130 (714)826-9049 (714) 826-9049 24-HOUR PHONE 126 24-HOUR PHONE 131 (714) 720-1204 (714) 231-5923 PAGER# 127 PAGER# 132 NA NA ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 NA Certification: Based on my inquiry of those individuals responsible for obtaining the information,I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true,accurate,and complete. SIGNA" F OWN RATOR ESIGNATED REPRESENTATIVE DATE).;y-M d 134 NAME OF DOCUMENT PREPARER 135 ./ Larry Sweetser NAME F SIG ER(pn vv o J 136 TIT '4_/GI4 GI/CI � A L4 yO� 37 S � UPCF(Rev.12/2007) OC UPCF 2/08#124 Distribution: White-OC CUPA Yellow-Responsible Agency Pink-Notifying Business o`? OCCUPA UNIFIED PROGRAM CONSOLIDATED FORM . '9� 1241 E.Dyer Rd Ste.120 HAZARDOUS WASTE V.yp� � Santa Ana,CA 92705 Tel:(714)433-6000 CERTIFICATION OF FINANCIAL ASSURANCE �'ziroS�~T M Fax:(714)754-1768 FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS 700.. . ❑ a. Initial Certification ❑ b. Amended Certification ❑ c. Annual Certification Page 3 of 5 I. FACILITY IDENTIFICATION •. (Put an asterisk in the left margin next to the amended information) BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3. Costa Mesa Sanitary District Household Hazardous Waste Facility FACILITY ID# I. FACILITY EP ID# 2. 3 0 CAH000378106 701. TYPE OF OPERATION ❑ a. PBR-FTU ❑ b. CA LI c. Other: Household Hazardous Waste PBR II. ESTIMATED CLOSURE COSTS NOTE: In addition to the dollar figure below,a written estimate of closure costs must be attached when you submit this section of this page. ESTIMATED CLOSURE COSTS: $ 13,457.14 702. III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS I am not required to provide a mechanism because: ❑ a. I certify that my closure cost estimate is less than or equal to$10,000,or 703. 704. ❑ b. Specify other reasons: 705. ❑ c. As a PBR owner or operator,I have not operated more than thirty days in a calendar year. (Does not apply to Conditional Authorization) IV.CLOSURE FINANCIAL ASSURANCE MECHANISM Q I am required to provide a mechanism and it is attached to this page.�/�/� 700 MECHANISM ID NUMBER(S): lax. 707. EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: MECHANISM TYPE ❑a. Closure Trust Fund ❑g. Multiple 7a�. �d. Closure Insurance Multi le Financial Mechanisms (Check one item only) ❑b. Surety Bond ❑e. Financial test and Corporate Guarantee ❑h. Certificate of Deposit ❑c. Closure Letter of Credit ❑f. Alternative Mechanism ❑i. Savings Account FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION 710. NA 711. ADDRESS NA 712. 713. 714. CITY STATE ZIP CODE V.OWNER OR OPERATOR CERTIFICATION SIGNER OF THIS CERTIFICATION 11 a. Owner ❑ b. Operator 7t5. 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 significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. (22 CCR Section 66270.11) 716. SIGNATURE OF OWNER/OPERATOR DATE - 717. 718. NAME OF OWNER/OPERATOR(Print) TITLE OF OWNER/OPERATOR &aft (q vvz Getke ire kt_Cak.G C e`i OC UPCFI/08#140 Distribution: White-Responsible Agency Pink-Notifying Business Formerly DTSC 1232 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 W. 19th Street, Costa Mesa, CA 92627-2716 Public Agency Official : Address : (if different from above) �=lam` Same 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 Costa Mesa Sanitary 7571 Lampson Avenue Estimate $ 13,457.14 District Household Garden Grove , CA 92841 CAH000378106 Date of Hazardous Waste Facility Estimate : 1/31/2014 Closure Cost Estimate: Date of Adjustment: Closure Cost Estimate: Date of Adjustment : Closure Cost Estimate: Date of Adjustment : 3 State of California-California Environmental Protection Agency Department of Toxic Substances Control CERTIFICATE OF SELF - INSURANCE 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 : 6, 7J' ,91 Typed or Printed name of Person Signing: Date : Sc # V ✓ o -2_,1// //4,7 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 CUPA use 7/20/99)