DTSC Form 8464 "Temporary Household Hazardous Waste Collection Facility Permit by Rule Notification" - California

What Is Form DTSC8464?

This is a legal form that was released by the California Department of Toxic Substances Control - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2007;
  • The latest edition provided by the California Department of Toxic Substances Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DTSC8464 by clicking the link below or browse more documents and templates provided by the California Department of Toxic Substances Control.

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Download DTSC Form 8464 "Temporary Household Hazardous Waste Collection Facility Permit by Rule Notification" - California

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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
TEMPORARY HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITY
PERMIT BY RULE NOTIFICATION
For use by public agencies operating a Temporary Household Hazardous Waste Collection Facility (THHWCF) under Permit By Rule. Each location requires a
separate form.
INITIAL NOTIFICATION
REVISED NOTIFICATION
Put an asterisk in the left margin next to the revised
information
I.
GENERAL INFORMATION
A.
FACILITY ID NUMBER
__________________________________
B.
FACILITY NAME
__________________________________
__________________________________
C.
FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY LOCATION
ADDRESS
_____________________________________
CITY
_________________
STATE ___
ZIP
___________________
COUNTY
_________________
D.
OPERATOR (PUBLIC AGENCY)
AGENCY NAME
___________________________________________________
___________________________________________________
MAILING ADDRESS
___________________________________________________
CITY
_________________
STATE ___
ZIP
____________________
COUNTY
_________________
E.
OPERATOR/AGENCY CONTACT PERSON INFORMATION
CONTACT PERSON
_____________
______________
(LAST NAME)
(FIRST NAME)
PHONE NUMBER
__________________
DTSC 8464 (revised 10/07)
PAGE 1 OF 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
TEMPORARY HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITY
PERMIT BY RULE NOTIFICATION
For use by public agencies operating a Temporary Household Hazardous Waste Collection Facility (THHWCF) under Permit By Rule. Each location requires a
separate form.
INITIAL NOTIFICATION
REVISED NOTIFICATION
Put an asterisk in the left margin next to the revised
information
I.
GENERAL INFORMATION
A.
FACILITY ID NUMBER
__________________________________
B.
FACILITY NAME
__________________________________
__________________________________
C.
FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY LOCATION
ADDRESS
_____________________________________
CITY
_________________
STATE ___
ZIP
___________________
COUNTY
_________________
D.
OPERATOR (PUBLIC AGENCY)
AGENCY NAME
___________________________________________________
___________________________________________________
MAILING ADDRESS
___________________________________________________
CITY
_________________
STATE ___
ZIP
____________________
COUNTY
_________________
E.
OPERATOR/AGENCY CONTACT PERSON INFORMATION
CONTACT PERSON
_____________
______________
(LAST NAME)
(FIRST NAME)
PHONE NUMBER
__________________
DTSC 8464 (revised 10/07)
PAGE 1 OF 4
TEMPORARY HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITY
PERMIT BY RULE NOTIFICATION
F.
CONTRACTOR INFORMATION (if applicable)
NAME ___________________________________
MAILING ADDRESS
___________________________
CITY
___________
STATE ____
ZIP
_____________
G.
CONTRACTOR CONTACT PERSON INFORMATION (if applicable)
CONTACT PERSON
_____________
_____________
(LAST NAME)
(FIRST NAME)
PHONE NUMBER
________________
H.
ACCEPTANCE OF CESQG WASTES
YES
NO
Will your facility accept wastes from conditionally exempt small quantity generators?
I.
THE FOLLOWING LOCAL AUTHORITIES HAVE BEEN NOTIFIED OF THE INTENDED
OPERATION OF THE THHWCF:
Environmental Management
Fire Department
Law Enforcement
Traffic
Air Quality
____________________________________________________
J.
THE FOLLOWING LOCAL PERMITS HAVE BEEN OBTAINED FOR OPERATION OF THE
THHWCF:
________________________________________________________________
________________________________________________________________
________________________________________________________________
DTSC 8464 (revised 10/07)
PAGE 2 OF 4
TEMPORARY HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITY
PERMIT BY RULE NOTIFICATION
K.
IS THE PROPERTY ON WHICH THE THHWCF WILL BE HELD OWNED BY THE OPERATOR
YES
NO
If not, a written agreement between the operator and the property owner is required.
PROPERTY OWNER’S NAME
_____________________________________
CONTACT PERSON
_____________
_____________
(LAST NAME)
(FIRST NAME)
PHONE NUMBER
________________
II.
DAYS AND HOURS OF OPERATION
Show hours using a 24-hour clock. Example:
1pm should be shown as 1300.
PLANNED DATES
HOURS
ALTERNATIVE DATES
HOURS
Month/Day/Year
Open
Close
Month/Day/Year
Open
Close
Example:
07 31 92
16:00
8:30
16:00
08
03
92
08:30
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DTSC 8464 (revised 10/07)
PAGE 3 OF 4
TEMPORARY HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITY
PERMIT BY RULE NOTIFICATION
III.
OPERATOR CERTIFICATION (PUBLIC AGENCY)
“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.”
________________________
_______________________________
Operator Name (Print or Type)
Title
_________________________________________________
_________________
Signature (Principal executive officer or ranking elected
Date Signed
Official), Title 22, Cal. Code Regs., section 66270.11 (a) (3)
Submit original notification to your Certified Unified Program Agency (CUPA)
Mail copy to DTSC:
Department of Toxic Substances Control, Regulatory and Program Development
th
Division – HHW Unit, P.O. Box 806, 11
floor, Sacramento, California 95812-0806
DTSC 8464 (revised 10/07)
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