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Scars of CaUtornu-Calitortoa EnsirommeoW Prvtncueo AgeWy Depar maim Of Toric Suiutaucas Comuni �hecc"nmper '_ Page 1 of ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION -k For Use by Hazardous Waste Generators Performing Treatment I]y Initial v UUnder Conditional Exemption and Conditional Authorization, ❑ Revised L and by Permit By Rule Facilities 3 y Please rein to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this { notificarion form, D7SC 1771. You must attach a separate unit specific notification form for each unir at this location. There are different unit specific notification form for each of the four categories and an additional notification form for transportable treatment units (771's). You only have to submit forms for the tiers) 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 _ of_'. Put vow EPA ID Number on each page. Please provide all of the information requested; allfields must be completed ezeept those shat state 'if differem' or 'if available'. Please type the information provided on this form and am attachments. The nonficarion will not be considered compiete without payment of the appropriate fee for each tier under which you are operating. (Please note that the fee is per TTER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, you only owe 51,140, NOT S times 51,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe 52,230.) 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. L NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you misr attach. Cortdrttarra/ty Fsanpr Small Qttaruuy Treatntou operations may rot,openae units under any other tier. Ntmtber of units and attached unit specific notifications Fee per Tier _ tlrtprrr!ut/ A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 B. Conditionally Exempt-Specified Wastesueam (Form DTSC 1772B) $ 100 C. Conditionally Authorized (Form DTSC 1772C) $1,140 D. permit by Rule (Form DTSC 1772D) x$11..140 Total Number of Units Total Fee Attached S H. GENERATOR MENTIFICATION EPA ID NUMBER CAS L.L 6 6 �©_1 BOE NUMBER (if available) HVA HQj(0 1� 9 g 5 9 NAME (Company or Facility) '" Q,�rL(�j� -- (DRA—Doimg Buunese AS) l '� PHYSICAL LOCATION ;) C For DTSC Use ONy CITY >�,C _,r;r� CA ZIP Ulf T�' - _ Region COUNTYi^ CONTACT PERSON .�IFV (j1 1 I-SII f PHONE NUMBER ) -`' (First W ) (Wt Nantes DTSC 1772 (1/93) Page I