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Stale of Cafiforma-C-forma Farinao PMda==Mjmcy *Mot Deparmmt of To=Subamwes C.muvi <br /> Page 1 of <br /> ONSITE HAZARDOUS WASTE TREA'TMEN'T NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Tr t.—*^tet ❑ Initial <br /> Under Conditional Ezems uon and Coaditio=Authorization, ❑_ Rtuewai <br /> and by Permit By Ruiz:Facilities ❑ Aflt:dn=t <br /> Pirate refer to the attached Instruafons before completing this form. You may norify for more than one permitting tier by tering this <br /> norfication form,DISC 1772. You trust attach a separate unit spedf c notification form for each unit at this location. There are- <br /> different unit sped,fhr notification formhs for each oftlhe four categories and an additional notification form for rrattspormble trcm ent <br /> units (77TI's). You only have to submit forms for the tie (s) that cover your mu(:). Discard or recycle the other unused fomu. <br /> Number each page of your carnplaed notification package and indicate the total number of pages at the top of each page at the <br /> 'Page_ of—'. Pur your EPA ID Number on each page. Please privvs& all of the inform anon requested- all felds must be <br /> cmWieted eccepr those that state 'if diffemnt' or 'if available. Please type the information provided on this form and any <br /> amaduments. <br /> The nor ication fees are assessed on the basis of the number of tiers the notifier will operate under,and will be cnilecre d by the Stan <br /> Board of Equalization. YOUR NZ WEM 7=NOTJ77CA77OAr FORM <br /> L NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. 71his will also be the number of unit specific notification forms you must attadi. <br /> CmdawmaUy Exempt Sn=U Quantity Tremnenr ope wwng may not op nue titins under any other ner <br /> Number of units and attached unit Specific notifications for each tier reported. <br /> A. Conditionally Exempt-Smtall Quantity Treatment D. Permit by Rule <br /> B. X-,j Conditionally Ezetapt-Specified Wwtestream E. Commercial Lnndry <br /> C. Conditionally Authorized F. Vurim= (Suction 75205.7) <br /> a. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAL923424231 —�` BOE NUMBER if available H_„_H Y OHC 30694346 <br /> FACILITY NAME Wal–Mart One Hour Photo #1789 <br /> (DSA—Doing Wsinm Aa) <br /> PHYSICAL LOCATION Kett 1 em a n Lane <br /> CITY Lodi CA ZIP 95242 _ <br /> COUNTY San Joaquin <br /> CONTACT PERSON Judy Coon PHONE NUMBER( 2 0 9) 36 8 - 0430 <br /> (Fiat Name) (LAK Name) <br /> MAULING ADDRESS, jF_pNT: <br /> COMPANY NAME Satre as above <br /> STREET <br /> eg;+m_ <br /> CITY STATE Zr? - <br /> COUNTRY <br /> {0ty&0wPiM 4Ax,vsA) <br /> CONTACT PERSON PHONE NUMBER(+ . <br /> (Furl Name) (Last Name) <br /> DTSC 1772(1195) Page i <br />