Laserfiche WebLink
State of Caiiforosa-California F.rironmemai Prot on Agency <br /> DeParmitnr of Toxic Sumtaoce Caouoi <br /> ONSITEPage I of r2- <br /> HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Initial <br /> Hazardous Waste Generators Performing Treatment <br /> Under Conditional Exemption and Conditional Authorization. Amended <br /> and by Permit By Rule Facilities <br /> Please refer rhe attached _n. you Instructions before comoletin¢this form. You may norifv for more than one permitting ti <br /> ermittiner by using this <br /> not{fication form. D2-SC 1 m. you attach a separate unit specific notification form for each unit ar this location. <br /> different unit saecific notiftcatiort tarns for five of the categories and an additional notifithere are <br /> cat <br /> =s). You only have to submit formr for the her(s)1categoryactioio Discard recycle the other unused <br /> (ier) that cover your n jorm for tnsportable treatment units <br /> ra <br /> ra <br /> forties. Number each page of your completed notification package and indipages at the rap of each page at <br /> complexed ucepr those that state 'if di <br /> the 'Page ei of—' Put your EPA !D Number on each page. cate the total number is Please provide all of the information requested: all fields mutt be <br /> attachments. different, or 'if available'. Please We the information provided on this form and arry <br /> the notification fees are assessed on the basis of the highest tier the natifter will operate under and will be collected by the State <br /> Board of Eaualizarion. DO NOT SEND YOUR FEE PAYMENT WITH <br /> THIS NOTrate under <br /> a FORM. <br /> F_ lly <br /> IFICATION CATEGORIES <br /> mber Of units you operate in each tier. This will also be the member of unit specific notification forms you <br /> ConditionallyExemptSmallQuantiiyTreatmentoperatorsmaynot operate units under any other tier. <br /> its and attached unit specific notifications for each tier reported. <br /> nditionally Exempt-SmallQuantity Treatment (CESQT) D. Permit by Rule (PBR) <br /> ditionally Exempt-Specified Wastestrram (CESW) E, CE-Commercial Laundry (CE-CL) <br /> ditionaliv Authorized (CA) <br /> F. Conditionally Exempt-Limited (CEL) <br /> if. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA1, ._Q 0 0 1 1 3 4 8 2 <br /> — — — _ BOE NUMBER (if available) H_HQ_ <br /> FACILITY NAME - - ---- <br /> DBA—Dome Business Ash <br /> PHYSICAL LOCATION 100 WEST LODI AVENUE <br /> CITY <br /> LODI CA ZIP 95240 <br /> COUNTY <br /> SAN JOAQUIN <br /> CONTACT PERSON <br /> xFN CANTRELL PHONE NUMBER( 209 ) 369 - 5853 <br /> Frost Namu <br /> STORE MANAGER �hsi Namo <br /> MAILING ADDRESS, IF DIFFERENT: <br /> C0MP.ANY NAME LONGS DRUG STORES CALIFORNIA, INC. <br /> STREET 141 NORTH CIVIC DRIVE <br /> CITY <br /> WALNUT CREEK STATE CA ZIP 94596 _ <br /> COUNTRY <br /> CONTACT PERSON only rKEITHt not USA) <br /> CANOES Namu PHONE NUMBER( 510 } 210 _ 6999 <br /> First [1st Namm <br /> ENVIRONMENTAL MANAGER <br /> DTSC 1772_ (1/96) <br /> Page I <br />