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.xaL of(ASforma•i-.tiforma iQ,i Aaeocv Deparmmr of Toric Svhas� <br /> Pige r C1 = <br /> r y/' ONSITE HAZARDOUS WASTE 'IREATMEN7 NOTIFICATION FORM <br /> 1" FACILSI-Y SPECIFIC NOTIFICATION <br /> For Use by Haardous Waste Ccaerators Performing Treatment -Iai 1�. <br /> SEP 0 8 1995 Under Condition i ExemDuon am Conditionai Authorization, t r xmewai <br /> and by Permit By Rule Facilities ❑ Amemucest <br /> Please refer to the artadhed Instructions before mmplaing this form. You may notify for more than one permming tier boe y using thus <br /> norifiearion form, DISC 1772. You mean attach a separate unit spec(fic norifieatton form for each unit at this location.' Ihare <br /> different unit specific notification forms for each of the four ostegonies and an additional norifrcarion form for trantpmrable tivnewx <br /> onus (ITV's). You only have to submit forms for the tier(s) that cover your unitis). Discara or reryde the otter unaged farms. <br /> Number each page of your completed notification package and indicate the total number of pages at the sop of each page ai the <br /> 'Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested; all frddr mart be <br /> completed except those that state 'if different' or 'if available'. Please type the information provided on thir fmm and act <br /> aaadunuus. <br /> The notification fees are assessed on the basis of the number of tiers the notifier will operate under, and will be collected by the State <br /> Board of Equalization. DO NOT MW POUR FFA W/77177IIS N0777,7Ct770N FORM <br /> L NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific norifrcarion formr pna intro atr� <br /> Ca+ditiowdly£sanpr Small Quantity Trraamenr operations may nor operate sorts under any other ries. <br /> Number of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quantity Treatment D. Permit by Rule <br /> B. X-,t Conditionaily Exempt-Specified Wastestream E. Commercial Laundry <br /> C Conditionally Authorized ] � g- Variance (Section=W.7) <br /> U. GENERATOR IDENTMCATION� �) <br /> EPA ID NUMBER CALQLCL: Z ____ BOE NUMBER (if avuiable) H_HQY=OHC 30-_694346 <br /> FACILITY NAME Wal-Hart Store#1554 One Hour Photo <br /> (DHA-Doing Bucaear Aa) <br /> PHYSICAL LOCATION 3702 East Hammer Road <br /> CITY Stockton CA ZIP95212 - <br /> COUNTY San ,7narnin <br /> CONTACT PERSON SheIia McDonald PHONE NUMBER( 209) 473 X854 <br /> (Fan Name) (W Name) <br /> MAILING ADDRESS, IF PIFF£RENT: <br /> COMPANY NAME Same as ah,ve <br /> For DT3C L'ae Lms 1 <br /> STREET actino _ P <br /> CITY STATE ZIP <br /> COUNTRY <br /> (ads<ompleae ii cot LSA) <br /> CONTACT PERSON PHONE NUMBER() <br /> (Fun Naiocl (Ln Namc) <br /> DISC 2772 (1)95) P4 i <br />