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Stele of rcroraia-(:atiforma Fariro®s , Prvt«om Agmry <br /> - DePartmmr of Toric Srb^•--es Cocom <br /> Page i of <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> ' FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment 9 <br /> EP 0 8 1935 G Under Conditional Exeinranon and Conditionai Authoziution. <br /> V icm�wai <br /> Iand by Permit By Rule Facilities 0 <br /> PleaaC,tKfer to,tifd anadwd Insrruaions before completing this form. You may nottfy for more than one permuting tier by using this <br /> noitfrea(ign form;DISC 1772. You must attach a separate unit specific notificarion form for each unit at this locathon There are <br /> different unit specific norification formr for each of the jour categories and an additional narlftcarion form for transporrable treannem <br /> units (17U's). You only have to submit forms for the rier(s) that cover your unit(s). Discard or recycle the other unuset jormr- <br /> Number each page of your completed norifrtntion 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 oil of the information requested; all fields must be <br /> completed except those that state 'if different' or 'if available'. Phare type the information provided on Chir form and ata <br /> attadunaus. <br /> the norification fees are assessed on the basis of the number of tiers the notifier will operate user, and will be collected by the State <br /> Board of Equalization. D0 NOT-WW YOUR FEF AMI71 7TW _0_7W A770N FORAf <br /> L NOTIFICATION CATEGORIES <br /> Indicate the manner of units you operate in each tier. This will also be the number of unit specific notificarion jams you must attar <br /> Conditionally FrMpt $mall Quantity Treatment opcatioat may not operate tours under any outer tier. <br /> Nmuber of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quantity Treatment D. Permit by Rule <br /> B. XX Cooditionaily Exempt-Specified Wmtestream E. Commercial Laundry <br /> C. Conditionally Authorized Q�q i F. Variance (Section 25205.7) <br /> 17. GENERATOR IDENTIFICATION C, <br /> EPA ID NUMBER CAL000I26635 ---- BOE NUMBER (if available) H_HQLSLLHC30 69434 <br /> FACILSIY NAME Wal-Mart One Hour Photo #2025 <br /> (DHA—Doins Huaiaeu Aa) <br /> PHYSICAL LOCATION 3070 west Grant Line Road <br /> CITY T rev CA Z.IP 9 5 37 6 - <br /> COUNTY San Joaquin <br /> CONTACT PERSON Lorena Martinez PHONE NUMBER 2( 29 ) 836 -_2 3 6 2 <br /> (Fort Name) (L"Name) <br /> MAELING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME a l as h v e <br /> r-or=C UW ods <br /> STREET <br /> Region— <br /> CITY <br /> ej1On—CITY STATE ZIP <br /> COUNTRY <br /> 4001r<omPkaa+faa USA) <br /> CONTACT PERSON PHONE NUMBER(_, ) - <br /> (Fim Nude) Nt Name) <br /> DTSC 1772 (1/95) Page i <br />