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SL.te of California-California Faviroumeattal ri -don AgmrY ... Department of Toxic Suhetancer Control 3 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION Y For Use by Hazardous Waste Generators Performing Treatment . 9 Initial UUnder Conditional Exemption anq Conditional Authorization, ❑ Revised y and by Permit By Rule Facilities Q E Please refer to the attached Instructions before completing this form. You may noth for more than one permitting tier by using this norification form, DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific notification forms for each of thefour caregories'and an additional notification form for transportable treatment units (7TU'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 _ of_'. 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 foreach tier under which you are operating. (Please note that the fee is per TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, you only owe$1,140, NOT 5 tirnm 31,140. !f 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 deck. Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. 7his will also be the number of unit specific notification forms you must attach. Conditionally Exempt Small Quantity Treatment operations a units under any other tier. �JUSeaY.. ; . .'.. Number of units and attached unit specific notificat ng apc 11 C Fee per Tier 4•.� o moo- - a (not per unit) A. 1 Conditionally Exempt-Small Quanty tment (Form 1772A) $ 100 B. 0 Conditionally Exempt-Specified V testrARIR 01( DTS 1772B) $ 100 C. 0 Conditionally Authorized otr�enLg„�� DTC 177X) $1,140 D. 0 Permit by Rule �f04AVE ” DTSC 1772D) $1,140 1 Total Number of Units Total Fee Attached $ 100.00 II. GENERATOR IDENTIFICATION EPA ID NUMBER CA D982042954 _ BOE NUMBER (if available) H_HQ 42-004890_ NAME (Company or Facility) LODI NEWS—SENTINEL (DBA—Doing Busimm Aa) PHYSICAL LOCATION 125 N . CHURCH ST. CITY LODI CA ZIP 95240 For DTSC U. Ordy Region COUNTY SAN JOAQUIN CONTACT PERSON JIM WEYBRET PHONE NUMBER 2( 09 ) 369 -2761 (First Name) (Lau Name) DTSC 1772 (1/93) Page I