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Stale of California-California Environmental Pro a Agency Department of To=Substances Control Check Number " '� /' i ^ Page l of 9 f�:2As7 w . 0 2 6 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment ® Initial Under Conditional Exemption and Conditional Authorization, ❑ Revised and by Permit By Rule Facilities Please refer to the attached Instructions before completing this form- You may notify for more than one permitting tier by using this notification form, D7SC 1772. You must attach a separate unit speck notification form for each unit at this location. There are different unit specific notification forms for each of the four categories and an additional notification form for transportable treatment units (T IV's). You only have to submit forms for the tier(s) that cover vour unit(s). Discard or recycle the other unused forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at the 'Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested; all fields must be completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any attachments. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that rhe fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, you only owe$1,140, NOT 5 times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA ID Number on the check Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notii icationformy you must attach. Conditionally Exempt Small Quantity Treatment operations may not operate units under any other tier. Nurnber of units and attached unit specific notifications Fee per Tier (not per wit) A. 0 Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. 0 Conditionally Exempt-Spec'¢�Wastestreetp (Form DTSC 1772B) $ 100 C. 0 Conditionally Authori °r Form DTSC 17720) $1,140 D. 1 Permit by Rule ' ( orm DTSC 1772D) / $1,140 A4'R6111993 1 Total Number of Units coi Hea,:! Jo...•sm Total Fee Attached $ 1 , 140 / II. GENERATOR IDENTIFICATIO SA F R A M E EPA ID NUMBER CA T 0 0 0 6 4 6 1 8 2 / BOE NUMBER (if available) HA HU I NAME (Company or Facility) Indy Electronics, Inc. (DBA—Doing Business As) PHYSICAL LOCATION 400 Industrial Park Drive For DTSC Use Only CITY Manteca CA ZIP 95336 _ COUNTY San Joaquin CONTACT PERSON Vl i 11 !am Price PHONE NUMBER � 9 ) 825 - 8314 (First Name) (Last Name) DTSC 1772 (1/93) Page I