Instructions for Form DTSC1093A "Standardized Permit Notification for Existing or Proposed Hazardous Waste Facilities" - California

This document contains official instructions for Form DTSC1093A, Standardized Permit Notification for Existing or Proposed Hazardous Waste Facilities - a form released and collected by the California Department of Toxic Substances Control.

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Download Instructions for Form DTSC1093A "Standardized Permit Notification for Existing or Proposed Hazardous Waste Facilities" - California

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California Environmental Protection Agency
Department of Toxic Substances Control
INSTRUCTIONS FOR COMPLETING
STANDARDIZED PERMIT NOTIFICATION FORM DTSC 1093 A
FOR EXISTING OR PROPOSED HAZARDOUS WASTE FACILITIES
Activities conducted under a standardized permit are limited to treatment and storage activities that do not
require a permit from the United States Environmental Protection Agency pursuant to the Resource Conservation
Recovery Act (RCRA).
Unless otherwise specified in the instructions to the form, each item must be answered. To indicate that each
item has been considered, enter "NA" for “not applicable” if a particular item does not fit the circumstances or
characteristics of your facility or activity.
SERIES DETERMINATION:
A. Indicate the total maximum volume and/or weight of hazardous waste that is or will be treated in any calendar
month under the standardized permit at this facility. This is the maximum monthly throughput.
B. Indicate the total storage capacity of the units that are or will be authorized to store hazardous wastes under the
standardized permit at this facility. This storage capacity is the maximum that the storage units will hold at any
one time; it is not the maximum monthly throughput.
:
INITIAL NOTIFICATION / REVISED NOTIFICATION
Indicate whether this is an initial, revised or permit renewal notification. A revised notification is required
whenever there is a change to the information required on the form. When completing a revised notification, please
place an asterisk (*) in the left margin next to the revised information.
I.
FACILITY INFORMATION
ID NUMBER:
Enter your facility Identification Number. This number should begin with the letters "CAL" or “CAD”, or “CAR”
etc. If you don't know your identification number or do not have an identification number, please contact the
Department of Toxic Substances (DTSC) Generator Information Services Section (GISS) at (800) 618-6942.
GISS will provide you with your number or send you an application form (Notification of Regulated Waste
Activity (EPA Form 8700-12)).
BOE NUMBER:
Enter your facility's Board of Equalization number. This number should begin with the letters "HF". If you do
not have a BOE number, please contact the Board of Equalization Excise Tax Unit at (916) 323-9555.
NAME:
Enter the facility's legal or "Doing Business As" (DBA) name. Do not use a colloquial name.
ADDRESS:
Give the address or location of the proposed or existing facility identified in Item I. of this form. Please note that
the address must be a physical address, not a post office box or route number. 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, for example, “at intersection Routes 425 and 22)”.
LOCATION:
Enter the major cross streets, or any land mark buildings/structures. For larger facilities or facilities in rural
area, enter the latitude and longitude at the approximate mid-point of the facility. Enter the latitude and
longitude of the facility in degrees, minutes, and seconds.
CONTACT:
Give the name (last name first), title, and work telephone number of a person who is thoroughly familiar with the
operation of the facility and the facts reported in this application and whom can be contacted by the reviewing
DTSC 1093B (8/2006 Instructions)
DRAFT
Page 1
California Environmental Protection Agency
Department of Toxic Substances Control
INSTRUCTIONS FOR COMPLETING
STANDARDIZED PERMIT NOTIFICATION FORM DTSC 1093 A
FOR EXISTING OR PROPOSED HAZARDOUS WASTE FACILITIES
Activities conducted under a standardized permit are limited to treatment and storage activities that do not
require a permit from the United States Environmental Protection Agency pursuant to the Resource Conservation
Recovery Act (RCRA).
Unless otherwise specified in the instructions to the form, each item must be answered. To indicate that each
item has been considered, enter "NA" for “not applicable” if a particular item does not fit the circumstances or
characteristics of your facility or activity.
SERIES DETERMINATION:
A. Indicate the total maximum volume and/or weight of hazardous waste that is or will be treated in any calendar
month under the standardized permit at this facility. This is the maximum monthly throughput.
B. Indicate the total storage capacity of the units that are or will be authorized to store hazardous wastes under the
standardized permit at this facility. This storage capacity is the maximum that the storage units will hold at any
one time; it is not the maximum monthly throughput.
:
INITIAL NOTIFICATION / REVISED NOTIFICATION
Indicate whether this is an initial, revised or permit renewal notification. A revised notification is required
whenever there is a change to the information required on the form. When completing a revised notification, please
place an asterisk (*) in the left margin next to the revised information.
I.
FACILITY INFORMATION
ID NUMBER:
Enter your facility Identification Number. This number should begin with the letters "CAL" or “CAD”, or “CAR”
etc. If you don't know your identification number or do not have an identification number, please contact the
Department of Toxic Substances (DTSC) Generator Information Services Section (GISS) at (800) 618-6942.
GISS will provide you with your number or send you an application form (Notification of Regulated Waste
Activity (EPA Form 8700-12)).
BOE NUMBER:
Enter your facility's Board of Equalization number. This number should begin with the letters "HF". If you do
not have a BOE number, please contact the Board of Equalization Excise Tax Unit at (916) 323-9555.
NAME:
Enter the facility's legal or "Doing Business As" (DBA) name. Do not use a colloquial name.
ADDRESS:
Give the address or location of the proposed or existing facility identified in Item I. of this form. Please note that
the address must be a physical address, not a post office box or route number. 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, for example, “at intersection Routes 425 and 22)”.
LOCATION:
Enter the major cross streets, or any land mark buildings/structures. For larger facilities or facilities in rural
area, enter the latitude and longitude at the approximate mid-point of the facility. Enter the latitude and
longitude of the facility in degrees, minutes, and seconds.
CONTACT:
Give the name (last name first), title, and work telephone number of a person who is thoroughly familiar with the
operation of the facility and the facts reported in this application and whom can be contacted by the reviewing
DTSC 1093B (8/2006 Instructions)
DRAFT
Page 1
California Environmental Protection Agency
Department of Toxic Substances Control
DTSC office if necessary.
II.
MAILING ADDRESS:
Please enter the Facility Mailing Address. If the Mailing Address and the Facility Location listed in Item I. are or
will be the same, you may print "same" in the space for Item II.
III.
FACILITY OPERATOR INFORMATION
NAME:
Give the legal name of the person, firm, public organization, or any other entity that operates or will operate the
facility described in this application. This may or may not be the same name as the facility. The operator of the
facility is the legal entity that controls the facility's operation; it may or may not be the plant or site manager. Do
not use a colloquial name.
ADDRESS:
Enter the address where the operator can be contacted.
TELEPHONE:
Enter the telephone number, including area code, where the operator can be contacted.
IV.
FACILITY OWNER
NAME:
Enter the name of the legal owner of the hazardous waste management facility. This may be a person or a
company.
ADDRESS:
Enter the address where this individual or a knowledgeable person within the company can be reached. If the
owner is located outside the United States, please complete the blank labeled "country".
TELEPHONE:
Enter the telephone number, including area code, where the owner can be contacted.
OWNERSHIP STATUS:
Indicate the legal status of the operator of the facility.
V.
LAND OWNER INFORMATION
NAME:
Enter the name of the legal owner of the property on which the facility is or will be located. If the land owner is
the same as the facility owner, write "same as facility owner”. If the land owner is the same as the operator,
write "same as facility operator".
ADDRESS:
Enter the address of the land owner. If the land owner is located outside of the United States, please complete
the blank labeled "Country".
TELEPHONE NUMBER:
Enter the telephone number of the land owner.
VI.
DESCRIPTION OF BUSINESS ACTIVITIES
SIC CODES:
List, in descending order of significance, up to four Standard Industrial Classification (SIC) codes that will best
describe your facility in terms of the principal products or services you produce or provide, or will produce or
provide.
Please do not use the SIC code for the hazardous waste treated or stored unless the
treatment/storage of hazardous waste will be your primary business. SIC code numbers are descriptions that
DTSC 1093B (8/2006 Instructions)
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California Environmental Protection Agency
Department of Toxic Substances Control
may be found in the "Standard Industrial Classification Manual" prepared by the Executive Office of the
President, Office of Management Budget, which is available from the Government Printing Office, Washington,
D.C. Use the current edition of the manual.
DESCRIPTION:
Briefly describe the nature of the business to be operated at the facility (e.g. "recycle used circuit boards to
reclaim gold").
VII.
FACILITY STATUS
A.
EXISTING ENVIRONMENTAL PERMITS:
Indicate all other environmental permits that the facility has, or for which the facility has filed or will file an
application, even if the permit has not yet been received.
NPDES = National Pollutant Discharge Elimination System, Clean Water Act; 42 U.S.C. 7401 et.seq.
Land use permit from the local land use or zoning agency
Local Industrial Sanitation District, wastewater pretreatment permit
TSCA (Toxic Substance Control Act) USEPA permits storing PCBs, pursuant to 40 CFR Part 761.
Permit by rule, pursuant to California Code of Regulations (22CCR) Section 66270.60.
Conditional authorization, pursuant to Health and Safety Code Section 25201.3.
Conditional exemption, pursuant to Health and Safety Code Section 25201.5(c). Note: facilities with a
standardized permit are not eligible for the small quantity conditional exemption pursuant to Section
25201.5(a).
Hazardous waste transporter registration; 22 CCR Chapter 13.
Other = any other relevant federal, state or local environmental permits or applications. Identify these.
B.
INDIAN LANDS:
Indicate whether the facility will be located on land owned by a designated Indian tribal authority.
VIII.
HAZARDOUS WASTE INFORMATION FOR ENTIRE SITE
A.
Indicate the total number of hazardous waste storage units that are or will be at the facility. An
example of one storage unit would be multiple tanks holding compatible waste within one bermed area, or one
bermed area holding several 55-gallon drums. Identify how many, if any, of these units/areas will be authorized
under a full facility permit and how many will be under the standardized permit.
B.
Indicate the total number of hazardous waste treatment units/processes that are or will be at the facility.
Indicate which of the total number of units will be authorized to operate under a full permit, under the
standardized permit, under permit by rule, under conditional authorization or under conditional exemption. A
"unit" is a combination of tanks or tank systems and/or containers located together that are used in sequence to
treat one or more compatible wastestreams. The devices are either plumbed together or otherwise linked so as
to form one treatment system.
For guidance on the appropriate applicability of the permit by rule, conditional authorization, and
conditional exemption requirements, see the Tiered Permitting Factsheet. You may obtain a copy of this
document from the DTSC website.
C.
Briefly describe all the hazardous waste treatment and storage activities that are or will be conducted
at the facility. Include a basic description of the activities and the purpose of the activities (e.g. "An aqueous
cyanide solution produced from electroplating is oxidized with hydrogen peroxide so that the waste may be
discharged directly into the county sewage system under the facility's permit from the sewage district"). Include
treatment under a full facility permit, permit by rule, treatment under conditional authorization, treatment under
conditional exemption and storage and/or treatment under the standardized permit. Annotate the description of
each of the storage or treatment activities as permit by rule (PBR), conditional authorization (CA), conditional
exemption (CE) or standardized permit (SP) as appropriate. Note that detailed unit-specific information forms
DTSC 1093B (8/2006 Instructions)
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California Environmental Protection Agency
Department of Toxic Substances Control
for each unit that manages wastes generated offsite are required attachments to this notification.
IX.
REQUIRED ATTACHMENTS
A/B/C DRAWING AND/OR BLUEPRINTS:
Each facility must include a facility location map and scaled drawings showing the general layout of the existing
or proposed facility. This drawing should be to scale and fit on an 8 1/2" by 11" sheet of paper. This drawing
should show the following:
1.
The property boundaries of the existing or proposed facility
2.
The areas to be occupied by all storage and treatment units. Annotate each area with the
Unit Name from the Unit-Specific Information Sheet(s);
3.
The approximate dimensions of each storage and treatment area; and.
4.
Security provisions (i.e. fences, gates, etc.)
D.
UNIT-SPECIFIC INFORMATION SHEETS
See Page 6 for instructions
X.
FACILITY OWNER CERTIFICATION:
All facility owners must sign Item X. Each copy of the notification form must have an original signature. If
the facility is or will be operated by someone other than the owner, then the operator must sign Item XI.
State regulations require the certification to be signed as follows:
A.
For a corporation, by a principal executive officer at least the level of vice president;
B.
For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or
C.
For a municipality, State, Federal, or other public facility, by either a principal executive officer or
ranking elected official.
The California Health and Safety Code provides for severe penalties for submitting false information on this
application form. Section 25191 of the Health and Safety Code states that any person who knowingly
makes a false statement or representation on an application or other document shall, upon conviction, be
punished by a fine of not less than $2,000 per day or more than $25,000 per day for each day of violation,
or by imprisonment, or both.
XI.
FACILITY OPERATOR CERTIFICATION:
All facility operators must sign Item XI. All copies must have original signatures. State regulations require
the certification to be signed as follows:
A.
For a corporation, by a principal executive officer at least the level of vice president;
B.
For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or
C.
For a municipality, State, Federal, or other public facility, by either a principal executive officer or
ranking elected official.
The California Health and Safety Code provides for severe penalties for submitting false information on this
application form. Section 25191 of the Health and Safety Code states that any person who knowingly
makes a false statement or representation on an application or other document shall, upon conviction, be
punished by a fine of not less than $2,000 per day or more than $25,000 per day for each day of violation, or
by imprisonment, or both.
XII.
LAND OWNER CERTIFICATION:
The legal owner of the land on which the facility is locates must sign Item XII. All copies must have original
signatures.
DTSC 1093B (8/2006 Instructions)
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California Environmental Protection Agency
Department of Toxic Substances Control
NOTIFICATION SUBMITTAL INSTRUCTIONS
Save one copy of the notification form for your files. Submit two copies of the notification form, each with
original signatures, and the required attachments via registered mail or other method which provides proof of
the date of mailing and receipt to the following address:
Department of Toxic Substances Control
Standardized Permitting and Corrective Action Branch
700 Heinz Avenue
Berkeley, California 94710
(510) 540-2122
DTSC 1093B (8/2006 Instructions)
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