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.^.'....,• .-.....u.,..- .-...aa u. ...ars u.....wuu a auu<uuu Agency Ueparunenl of Toxic Substeoces Control F5;;7k Number tit J Page 1 of R 9 2 0 0''(� 2 6 Li ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment ❑ Initial V Under Conditional Exemption and Conditional Authorization, ❑ Revised C and by Permit By Rule Facilities tl y` Please refer to the attached Instructions before completing this form. You may not fy for more than one permitting tier by using this ! notification form, DISC 1772. You must attach a separate unit specific notifcation form for each unit at this location. There are different unit specific notification forms far each of rhe four categories and an additional notif cation form for transportable treatment units (TTfI'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 ofyour completed notification package and indicate the total number ofpages 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 fteldr 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 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$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA M Number on the check Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific not f cation forms you must attach. ConditionallyF-zmWtSmall Quantity Treatment operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier /A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) (not per untq$ 100 B. Conditionally Exempt-SpecifiedW trfami' / ^o,; rm DTSC 1772B) $ 100 r l :. ,. )of PA n C. Conditionally Authorized ac °(�dgn TSC 17720) $1,140 D. Permit by Rule (Fofm SC 1772D) $1,140 APR 011993 Total Number of Units Calitorr;k Oc-nrtmem 6liean„;,ej.czu Total Fee Attached $100,OJ II. GENERATOR IDENTIFICATION s q c ri A M a',i EPA ID NUMBER CAL 0 0 2 ip 4/ j p =nr BOE NUMBER (if available) H_HQ______ _ NAME (Company or Facility) K/P F} S PHYSICBusiness AL LOCATION Ff rl cm R I S e_ CITY ST WX iVly For DTSC Use Only CA ZIP "'020 - I COUNTY Region SAN Joac��u�t� CONTACT PERSON W I LLI rm _ HE( ( PHONE NUMBER( lid ) n (Fent Name) (last Name) Page 1 DTSC 1772 (1/93)