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Stats of Californa-California Farirnomental Protr i Agency . Department of Toric Substances Coetrd <br /> Check Number \Q N \� Page 1 of <br /> 11� 92 00033 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> yFor Use by Hazardous Waste Generators Performing Treatment ® Initial <br /> j Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> u and by Permit By Rule Facilities <br /> Please refer to the attached Instruction before completing this form. You may notify for more than one permitting tier by using this <br /> notification form, DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for each of the four categories and an additional notification form for transportable treatment <br /> units (TTU'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 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 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 77ER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT S 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 notification forms you must attach. <br /> Conditionally Fionpt Stall Quantity Treatment operations may not operate units under any other tier. <br /> Number of tants and attached unit specific notifications Fee per Tier <br /> (not per wit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 <br /> B. �_ Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) Si,140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> 1 Total Number of Units - ) - Total Fee Attached S 1 no <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAL` Q _a _Q 11212 4 BOE NUMBER (if available) H_HQ__ <br /> NAME (Company or Facility) Isings Culligan Water of San Joaauin Valley <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 1226 Enterprise <br /> For DTSC Uu Only <br /> CITY Stnckton CA ZIP q5204 <br /> Region <br /> COUNTY San Jnaauin <br /> CONTACT PERSON Linda Adams PHONE NUMBER(20L,466 -2501 <br /> (Firm Name) ltau Name) <br /> DTSC 1772 (1/93) VAL-_4D " GL Page I <br />