COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

oi Number Page I of 0 0 0"4 2 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment ❑ Initial J4L Under Conditional Exemption and Conditional Authorization, ❑ Revised and by Permit By Rule Facilities C 3 t7t Please refer to the attached Instructions before completing this form. You may notes for more than one permitting tin by using this j norification form, DISC 1772. You must attach a separate unit specific notificationform for each unit at this location. There are different unit specific not fcation forms for each of the jour categories and an additional not f cation form for transportable treatment units (TTU's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at the 'Page _ oj_'. Put your EPA ID Number on each page. Please provide all of the information requested, all fields must be completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any attachments. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that rhe fee is per 77ER not per UNIT. For example, if you operate 5 units but thev are all Conditionally Authori ed, you only owe$1,140, NOT times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe $2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA ID Number on the check. Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you must attach. Conditionally Exempt Small Quantity Treatment operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier snot per unit) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 B. 3 Conditionally Exempt-Specified Wastestream (Form DISC 1772B) / S 100 C. Conditionally Authorized f (Form DTSC 1772C) 51,140 D. Permit by Rule `• (Form DTSC 1772D) SI•I40 Total Number of Units ` S�ycN70, / Total Fee Attached S �00 11. GENERATOR IDENTIFICATION q / EPA ID NUMBER CAC' A D. O � 1- 1 1 D 6 BOE NUMBER (if available) H&HQ 6_Q_ z I ► 11 NAME (Company or Facility) Sr .TosRWs 0CDJC9C. Gen tV__ iDBA—Doing Business As) - PHYSICAL LOCATION I oo N. CHGI 0R NI A Sr 1 EFor DTSC ,Jniy CITY S-rper--ltr,) CA04 ZIP 9sao Region 'OUNTY SQ V) o4pylN CONTACT PERSON FrfgaK CRO19 PHONE NUMBER(,20 )-- 6363 (Fins Name) (Lav Name) DTSC 1772 (1193) Page I