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Stnte or CAUfarlda.CRUornis EaritnaTt cnW "nfeetion Agency De;�tmar'of Tmde Su4stow"Control _.eek Nu r Page I of L 19aa 9 2 00 0 1 5 i ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM y FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment ® Initial UUnder Conditional Exemption and Conditional Authorization, 0 Revised and by Permit By Rule Facilities 0 Please refer to the attached instructions before completing this form. You may notify for more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific norffiearion forms for each of thefour categories and an additional notfcationform for transportable treatment units (17TI'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_'. Pur 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 We the information provided on this forst and any attachments. The notification will not be considered complete without payment of the appropriate fee for each 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 times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe$2,280.) Chucks 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. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you must anach. Conduiowlly Zxenpt Small Quantity Trmunent operations may not operate units runlet any other aff Number of units and attached urtit specific notifications Fee per Tier _ ,��--_ (oat per urdo A. Conditionally Exempt-Small 4ruanu��„irwWaiiht (Form DTSC 1772A) $ 100 J fi, B. 1 - Conditionally Exempt-SpectfieFl;Yivastesheam (Form DTSC 1772B) $ 100 C. Conditionally Authori (Form DTSC 17720) $1,140 D. Permit by Rule PARR 3 3 ?993 (Form DTSC 1772D) $1,140 —___ California Oapanmont ---a----- d Haa;In Servicas 1 Total Number of Units s`)CSAM000 Total Fee Attached $ 100.00 11. GENERATOR EDENTIFICATION EPA ID NUMBER CA 0 0 0 0 0 6 6 9 5 7 / BOB NUMBER (if available) H AHQ 3 6 1 0 2 0 9 5 NAME (Company or Facility) lief n z, U.S.A. (DBA-Doing Rueinen As) PHYSICAL LOCATION 2800 So -h .a 1 i forni a Str et CITY Stockton CA ZIP 95206 For DTSC Use only Region COUNTY SR ty 7-64Q,", U1, CONTACT PERSON Kurt Bra USO PHONE NUMBER 2( 09 ) 948 - 2782 (Fast Name) (torah Name) DTSC 1772 (1193) Page I 6%6'd ZNI3H'f-H ES:90 66. 06 adw