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State'of California - California Eunrouweawl 11rotecuun Agency Department of Tuxic Subii: es Cumrui - <br /> .<e Page I of tri <br /> 92 00050 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> y°1 FACILITY SPECIFIC NOTIFICATION <br /> U For Use by Hazardous Waste Generators Performing Treatment Q Initial <br /> o Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> Please refer to the attached instructions before completing this form. You may notes for more than one permitting tier by using this <br /> notification form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific norihcationforms for each of thefour categories and an additional notifcationform for transportable treatmenr <br /> units (77'U's). You only have to submit forms for the tier(s) that cover your unii(s). Discard or recycle the other unused jorms. <br /> ,Number each page of your completed notification pac.(nge and indicate the total number of pages at the top of each page at rite <br /> 'Page _ of— <br /> pt those that state 'if different' or 'if available'. Please type the information provided on this jorm and an <br /> attachments. <br /> The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operaturg. <br /> (Please note that thefee is per TIER not per UNIT. For example, if you operate 5 units but they are all Conditionallv.iuthorized, <br /> you only owe$1,140, NOT5 timer$1,140. If you operate any Permit by Rule units and any units under Conditional Aurhorizati, n <br /> you owe S2,2W.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this <br /> form. Please write your EPA iD Number on the check. Fill in the check number in the box above. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notificationforms you must auach.'� <br /> Conditionally Exempt Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (not per unit, <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. Conditionally Exempt-S as /\ �;�i"ptllyr (Form DTSC 1772B) S 100 <br /> \lance c <br /> C. _X Conditionally Autho zeci., ° e F s (Form DTSC 1772C) $I,140 <br /> D. Permit by Rule 9� om �_ (Form DTSC 1772D) <br /> $1,140 <br /> sasaa sy. GQ <br /> 1 Total Number of o Total Fee Attached $ 1140 <br /> U u 0 <br /> R. GENERATOR mENTiFICA ° " °y lz <br /> EPA ID NUMBER CAD 0 9 5 6 5 4_ _ _ BOE NUMBER (if available) HgHQ 0 3 6 0 2 3 3 7 3 <br /> NAME (Company or Facility) R.V. Circuits , Inc. <br /> tDBA- Doing Business As) g <br /> PHYSICAL LOCATION 16 S. Center St . <br /> For DTSC Uae Only <br /> CITY Stockton CA Zlp95206 - 1310 <br /> Rozion � <br /> COUNTY San Joaquin <br /> CONTACT PERSON Arthur' Smith PHONE NUMBER( 209) 464 4562 <br /> (First Name) (Last Name) <br /> DTSC 1772 (1/93) �L .t eJ Q r. <br /> V ' 1 -1r.� 1';f',: � . .l J�: • Page 1 <br />