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-1.1 ",,,1.,.....1 u....1,.�.r..�.....uLL...,.woc.u.rtgc y <br /> ' <br /> Check llePatLuent o!Tozic Substances Control <br /> v y Page 1 of 4 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> y FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment ❑ <br /> VInitial <br /> Under Conditional Exemption anConditional Authorization, <br /> v tid ❑ Revised <br /> a and by Permit By Rule Facilities <br /> y Please refer to the attached Instructions before completing this form. You may not fy far more than one permitting tier by using this <br /> notification form, DISC 1772, You must attach a separate unit specific 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 notif cation form for transportable treatment <br /> units (77T1's). 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 ofpages 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 71ER not per UNIT. For example, ifyou 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 notif cation forms you must attach. <br /> ConditionaUyExenpt 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 /> A. Conditional] Exempt-Small (not per unit/ <br /> Conditionally p Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. Conditionally Exempt-Specified Wastestream (Form DTSC 177213) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D• _Permit by Rule (Form DTSC 1772D) $1,140 <br /> Total Number of Units Total Fee Attached $100103 <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAL0 p 12 ' <br /> —_� �� O J BOE NUMBER (if available) H_HQ_ <br /> NAME (Company or Facility) KAP 601 VWOI <br /> (DBA—Doing Businew As) - <br /> PHYSICAL LOCATION <br /> For DTSC Use Only <br /> CITY STDC�-rC�l�l CA ZIP '�0� - <br /> COUNTYRegion <br /> SFlI� Joao�u�N <br /> CONTACT PERSON W I W ftM r 1CI t PHONE NUMBER( D f ) 14 _ 6761 <br /> (Pint Name) (tau Name <br /> DTSC 1772 (1/93) Pago I <br />