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Soul of California-California Fariro®ental R tion Agency Depornmt of Tone Submaaes Cantron <br /> Check Number — Page I of_E <br /> 2 L4 tol 92 00 0 1 5 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> t For Use by Hazardous Waste Generators Performing Treatment IN initial <br /> 1 Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> J <br /> � and by Permit By Rule Facilities <br /> 7) Please refer to the attached Instructions before completing this form. You may notifyfor more than one permitting tier by using this <br /> notication form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit speck notification forms for each of thefour categories and an additional notificationform for transportable treatment <br /> units (7711's). You only have to submit forms for the tier(s) that rover 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 the.:e that state 'if different' or 'if available'. Please We the irrformation 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 mote that tate fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, MOTS times$1,140. If you operate any Permit by Rule units ata c•^' ""•'" ""a"' <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 /D 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 notification forms you must attach. <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 /> Inot per unit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 <br /> B. 1 Conditionally Exempt-Speci �> 95 (Form DTSC 1772B) $ 100 <br /> SJb GB& Enfor,,, V <br /> C. Conditionally Authori �+ (Form DTSC 17720) $1,140 <br /> D. Permit by Rule " = orm DTSC 1772D) $1,140 <br /> s= PAAR 31 1993 --'------ <br /> 1 Total Number of Units cof RQif,Q,° a„"e;" Total Fee Attached $ 100 <br /> II. GENERATOR IDENTIFICATIO 04CRAME00 <br /> EPA ID NUMBER 3- BOE NUMBER (if available) H Y 5 <br /> NAME (Company or Facility) A. Teichert & Son, Inc. <br /> (DBA—Doing Busimw As) <br /> PHYSICAL LOCATION Mobile Equipment–Stockton Shop <br /> 103 North E Street <br /> For DTSC Use Only <br /> CITY Stockton CA ZIP 95205 - 1 <br /> Region <br /> COUNTY San Joaquin <br /> CONTACT PERSON George Takemori PHONE NUMBER(2L6)386 -6916 <br /> (Firu Nsme) (IJu Nsrne) <br /> DTSC 1772 (1/93) Page 1 <br />