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State of C:life nia-California Emit ental Pr^tectiou Agency D"rocimt of Toxic Substances Control <br /> Page 1 of <br /> ONSITE HUARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> a IQ For Use by Hazardous Waste Generators Performing Treatment Initial <br /> -� Under Conditional Exemption and Conditional Authorization, ❑ Renewal <br /> and by Permit By Rule Facilities ❑ Revision <br /> Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> not f cation form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific not(cation forns for each of the four categories and an additional not f cation form for transportable treatment <br /> units (TrU s). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. <br /> Number each page of your completed notification 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 /> Due not f cation 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 SEND YOUR FEE Wr77 77US N077F7C.1770N 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 notificationjorms you must attach. <br /> Conditionally Erm" Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of units and attach unit specific notifications for each tier reported. <br /> A. i Conditionally Exempt-Small Quantity Treatment D. Permit by Rule <br /> B. Conditionally Exempt-Specified Wastestream E. Commercial Laundry <br /> C. Conditionally Authorized F. Variance (Section 25205.7) <br /> IL GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA D 9 �3 3 ( C Q O g BOE NUMBER (if available) H_HQ____ <br /> FACILITY NAME pQ 3 i 1 10ry<= poy 2 (Jcy ) cj <br /> (DBA—Doing Busineas As) M <br /> PHYSICAL LOCATION <br /> CITY m CJ ry C E Cn CA( ,ZIPS 5 3:3 <br /> COUNTY K A(-/ 6 P y v > <br /> CONTACT PERSON �!J\ _ Q• PHONE NUMBER( 2_y9)ZQ_-(32-ZO <br /> (Fiat Nance) (lact Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME <br /> STREET <br /> CITY STATE ZIP <br /> COUNTRY <br /> (only complete if rat USA) <br /> CONTACT PERSON PHONE NUMBER( ) <br /> (Fins Name) (Leal Name) <br /> DTSC 1772 (7194) Page I <br />