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Stale^.f California-California Faviroumentr' _`otection Agency Departweul of Toxic Substances Con" <br /> Page I of <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> F Use by Hazardous Waste Generators Performing Treatment Initial <br /> 95 MAR –1 QM 1 ' 1Under 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 notes for more than one permitting tier by using this <br /> not f cation form, D7SC 1771. 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 the four categories and an additional notification form for transportable treatment <br /> units (77'II'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 /> 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 Equaliuuion. DO NOT SEND YOUR FEE VIrM 77HS NOTMCA77ON FORM. <br /> 1. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you must attach. <br /> Conditionally Exempt Small Quantity Treatment operations may not operate unity under any other tier. <br /> Number or units and attached unit specific notifications for each tier reported. <br /> A. 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 /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA 1) O 4 0 8 BOE NUMBER (if available) H—HQ <br /> -- <br /> FACILITY NAME )S AI -f G tilOC/1, ONO-Tri — <br /> �C� \ .W <br /> (DBA—[Ming Businew As) <br /> PHYSICAL LOCATION53 6Um gSA <br /> CITY CA CA ZIP 9S 33 t, - <br /> COUNTY SA �JOtI�U�i <br /> CONTACT PERSON �Ay i f'lA n C PHONE NUMBER ' aC X23 -O ZZo <br /> (I im Name) (Last Nana:) <br /> MAILING ADDRESS, tF DIFFERENT: <br /> COMPANY NAME <br /> STREET <br /> CITY STATE ZIP <br /> COUNTRY <br /> — --- (only complete if not USA) <br /> CONTACT PERSON PHONE NUMBERS ) <br /> (Firal Name) (LAW Name) <br /> DTSC 1772 (7/94) Page I <br />