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State of California-California Environmental tectioo Agency Departruenl of Toxic Suhetaocer Coo <br /> Check Number Page I of" <br /> y ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment 0" Initial <br /> U Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> ry Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> notification form, D7SC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for each of rhe four categories and an additional not f cation form for transportable treatment <br /> units ('ITV's). You only have to submit forms for the tier(s) that cover your unii(s). Discard or recycle the other unused forms. <br /> Number each page of your completed norification 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 form and any <br /> attachments. <br /> The notification will not be considered complete without payment of the appropridtefee for each tier under which you are operating. <br /> (Please note that the fee is per TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT 5 times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this <br /> form. Please write your EPA ID Number on the check. Fill in the check number in the box above. <br /> L NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific not f cation forms you must attach. <br /> CondilionaUy Exempt Small Quantity Treatment operations may not operate unity wrier any other tier. <br /> Number of/units and attached unit specific notifications ee per Tier <br /> . Imly mot per unit) <br /> A. Conditionally Exempt-Small Quan4ty Treatment (Form DTSC 1772A) E C $ 100 <br /> B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) JUN 2 0 1994 $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) ENVIRONMENTAL HrALTH $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) PERMIT/SERVICES $1,140 <br /> Total Number of Units Total Fee Attached $�%, <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA C_o (' �Q 03304 BOE NUMBER (if available) H_HQ__ _ <br /> NAME (Company or Facility) �,� ' - ti fve>M P <br /> (DBA—Doing Business Aa) <br /> PHYSICAL LOCATION <br /> CITYCA ZIP JJ For DTSC Use Only <br /> ys�TU <br /> N Region <br /> COUNTY <br /> CONTACT PERSON Q-Spin PHONE NUMBER(aoV_46g-� <br /> (Fiat Nafitef Name) <br /> DTSC 1772 (1/93) Page 1 <br />