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�t Sb to of Calfornia-California Fu imumm• ' Pmte t ou Agency <br /> Chale u r Departarent of Toxic Subsuma Cootrd <br /> 033645 Pre : of 3 <br /> I <br /> 21 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> ` FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treat me 4.-, - ® Initial <br /> V Under Conditional Exemption an <br /> 4 Conditional Authorizahonrw <br /> o ❑ Revised <br /> C and by Permit By Rule Facilities "UNMENTAL I-P <br /> PERMIT/SERVi� _ <br /> y 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, DTSC 1772. You must attach a separate unit spec fc not(cation form for each unit at this location. There are <br /> different unit specific not(cation forms for each of the four categories and an additional not fcatiotiform for transportable treatmentreare <br /> units (7TU'sJ. You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. <br /> Number each page of your completed notification package and indicate the total number of pages at the top of each page at the <br /> '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 will not be considered complete without payment of the appropriate fee for each tier under which you are operating. <br /> (Please note that the fee is per TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> YOU only owe $1,140, NOT 5 times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe$2,280.) 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 not f cation forms you must attach. <br /> CunditionaUy 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. _1 Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. 0 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. 0 Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> 0 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> 1 <br /> Total Number of Units Total Fee Attached $ 100.00 <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA D982042954 — — — — BOE NUMBER (if available) H—H 42-004890 <br /> NAME (Company or Facility) LODI NEWS-SENTINEL <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 125 N. CHURCH ST. <br /> f3A <br /> CITY <br /> LODI CA ZIP 95240 For DTSC Uu Only <br /> Region <br /> COUNTY SAN JOAQUIN <br /> CONTACT PERSON JIM WEYBRET PHONE NUMBER 2( O9 ) 369 -2761 <br /> (Firu Name) (tip Name) <br /> DTSC 1772 (1/93) Page I <br />