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Page 1 of <br /> -ONSITE GoS WASTE TREATMENT Nu-,7bn,�,��_ <br /> +ORM <br /> FACILITY SPECIFIC NOTIFICATIONo csmc Initial <br /> For Use by Hazardous Waste Generators Performing Tr "� ended <br /> Under Conditional Exemption and Conditional Authoriza ;•i6 and by Permit By Rule Facilities <br /> 1996 <br /> Please refer to the attached Instructions before completing this form. You may notify for re than one permitting tier by ing this <br /> notification form, DTSC 1772. You must attach a separate unit specific notification form f each unit at this location There are <br /> different unit specific notification forms for five of the categories and an additional notification rm f?r transportole t atment units <br /> (ITV's). You only have to submit forms for the tiers)/category(ies) that cover your unit(s).. Di idDoy"k€e c� a other unused <br /> forms. Number each page of your completed notification package and indicate the total number of pages a t e top of each page at <br /> the 'Page_ of_'. Put your EPA ID Number on each page. Please provide all of the information requested; all fields must be <br /> completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any <br /> attachments. <br /> The notification fees are assessed on the basis of the highest tier the notifier will operate under and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE PAYMENT WITH THIS NOTIFICATION FORM <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you <br /> must attach. Conditionally Exempt Small Quantity Treatment operators may not operate units under any other tier. <br /> Number of units and attached unit specific notifications for each tier reported. <br /> A. _ Conditionally Exempt-Small Quantity Treatment (CESQT) D. Permit by Rule (PBR) <br /> I' -hO000ConditionallyExempt-Specified Wastestream (CESW) E. CE--Commercial Laundry (CE-CL) <br /> C. Conditionally Authorized (CA) F. Conditionally Exempt-Limited (CEL) <br /> IL GENERATOR IDENTIFICATION <br /> 0 <br /> EPA ID NUMBER CA'�>g (� (p 1 O �'� BOE NUMBER (if available) H 1HQ 3 6 o I Q lis- 9 <br /> FACILITY NAME -he, P� fdj o X13 -- KcLm .1 _Mo ea K Jac (A Cie Al; 710 , <br /> (DBA—Doing Business As) 1 <br /> PHYSICAL LOCATION ?V56 � gA+ <br /> CITY 344 e k fo /1 CA ZIP 15RCk- / <br /> COUNTY {�,Sa� J oq c L4A J 1 �, <br /> CONTACT PERSON `�VSSZ\` ` �LL-X `Q t\fit/ PHONE NUMBER(aIS)22-7-9193 <br /> (First Name) (Last Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME �¢ �'2 �jo $ ("1 Kd JgLh <br /> STREET 3, \11 we5x AkkfI1 Kti Ave.vtiue_ <br /> CITY STATE Ptk ZIP 14132- <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON Rqs%Q(( �-tcc tarrle «O PHONE NUMBER(Rk5' 12.7 -4193 <br /> (First Name) (last Name) <br /> DTSC 1772 (1/96) Page I <br />