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� � �lldrsr`` <br /> State of California-Califoraia Eaviso mental Prolectim AgeaY D —"JAN 18'—•1996 jawnw*of Toric SuE�aoca conoid <br /> I I �I I Page 1 of_ <br /> ONStT•E, WARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTtFICA`9IORJaAQuu,C) <br /> For Use by Hazardous Waste Generators Perfo ` i` l F g 'i ❑ Initial <br /> Under Conditional Exemption and Conditional Authorization, ❑ Reaewal <br /> and by Permit By Rule Facilities ® Ameodmnu <br /> Please refer to the attached Instri mons before completing this form. You may noth jar more than one permitting tier by using this <br /> notificationform, DISC 1772. You must attach a separate unit speck notification form for each unit at this location. 7hereare <br /> different unit specific notication forms for each of the jour categories and an additional notication form for transportable treatment <br /> units (77-U's). You only have to submit forms for the der(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 jam and any <br /> attachments. <br /> The notificationfees are assessed on the basis of the number of tiers the notifier will operate under, and will be collected by the State <br /> Board ojEqualization. DO NOT SEND YOUR FEE VMH TWS N071FICA 70N FORM. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit speck notificationforms you must attach <br /> Conditionally Eronpt Small Quantity Rearment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quantity Treatment D. _5 Permit by Rule <br /> B. Conditionally Exempt-Specified Wastestream E. Commercial Laundry <br /> C. Conditionally Authorized F. Variance (Section 25143) <br /> II. GENERATOR IDENTIFICATION G'. 1 <br /> EPA ID NUMBER CA O O O O$,lBOE NUMBER (if available) H_HQ_ __ _ ____ <br /> FACILITY NAME rtP 404C'LD MP7-/4J E-1-1IV <br /> (DBA--Doing Suainesa Aa) <br /> PHYSICAL LOCATION 4,1,2I C l Y4NAtVC lit ! Z-b,4 n1 <br /> CITY —mTU _K fir n1 CA ZIP cl 52C)4b <br /> COUNTY S jq� 1 E k4 Rl u I N <br /> CONTACT PERSON CTM mr-'S �)CwN rr,1 r ` I PHONE NUMBER 2( V_.2)`l k'1-_)__LL_1L <br /> (Firm Nana) (1/am Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME For DTSC Use Ody <br /> STREET Region <br /> CITY STATE ZIP <br /> COUNTRY <br /> (ody complete if rot USA) <br /> CONTACT PERSON PHONE NUMBER(___)_- <br /> (Fint Nam) (tart Name) <br /> DTSC 1772 (1/95) Page 1 <br />