Form DTSC1094B "Permit by Rule Notification for Proposed Facilities" - California

What Is Form DTSC1094B?

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 November 1, 2008;
  • 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 DTSC1094B 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 Form DTSC1094B "Permit by Rule Notification for Proposed Facilities" - California

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INSTRUCTIONS FOR COMPLETING
PERMANENT HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITY PERMIT BY RULE NOTIFICATION
FOR PROPOSED FACILITIES
FORM DTSC 1094B
For use by public agencies proposing to operate a permanent household hazardous waste collection facility
(PHHWCF).
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
"CAH". 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.
II.
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
INSTRUCTIONS FOR COMPLETING
PERMANENT HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITY PERMIT BY RULE NOTIFICATION
FOR PROPOSED FACILITIES
FORM DTSC 1094B
For use by public agencies proposing to operate a permanent household hazardous waste collection facility
(PHHWCF).
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
"CAH". 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.
II.
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 entities, 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 1094B Instructions (Revised 11/08)
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
PHHWCF in an average month. Please indicate this figure in either gallons 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 PHHWCF 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 8½" 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).
DTSC 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 1094B (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, 11th floor
Sacramento, California 95812-0806
DTSC 1094B Instructions (Revised 11/08)
Page 4
State of California - California Environmental Protection Agency
Department of Toxic Substances Control
PERMIT BY RULE NOTIFICATION FORM
For DTSC Use Only
FOR PERMANENT HOUSEHOLD
HAZARDOUS WASTE COLLECTION FACILITIES
Region _____________
Please refer to the attached Instructions before completing this form.
Initial Notification
Revised Notification
I.
GENERAL INFORMATION
ID NUMBER: CA__ __ __ __ __ __ __ __ __ __
FACILITY NAME
_____________________________________________________________________
FACILITY ADDRESS
_____________________________________________________________________
_____________________________________________________________________
CITY
_______________________________ CA
ZIP _________-______
COUNTY
_______________________________
LOCATION
_____________________________________________________________________
(Description)
_____________________________________________________________________
(Latitude & Longitude)
_____________________________________________________________________
II.
OPERATOR (PUBLIC AGENCY)
NAME
_____________________________________________________________________
ADDRESS
_____________________________________________________________________
_____________________________________________________________________
CITY
____________________________ STATE ____ ZIP ________-______
CONTACT PERSON
________________________
________________________
(Last Name)
(First Name)
TELEPHONE NUMBER (_____)______-________
III.
CONTRACTOR INFORMATION (if applicable)
NAME
_____________________________________________________________________
ADDRESS
_____________________________________________________________________
_____________________________________________________________________
CITY
____________________________ STATE ____ ZIP ________-______
CONTACT PERSON
________________________
________________________
(Last Name)
(First Name)
TELEPHONE NUMBER (_____)______-________
DTSC 1094B (Revised 11/08)
Page 1