COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Department of Toxic SubstauceS Control .:State of California-CaBm fora FavmoamemW ` itmfion Agency Page 1 of Check Number / ' V T2 g 3 1 0 0 1 6 DF L ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION ter v 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 not fy for more than one permitting tier by using this notification form,DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific notification forms for each of the four categories and an additional notificationform for transportable treatment units (77TI's). You only have to submit forms for the tier(s) that cover your 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 the 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 notification forms you must attach. ConditionallyF-mmpt Small Quantity Treatment operations may not operate units under any other tier. Number of units and attached unit specific notifications a Services Fee Tier ON%09etations SPS/lis (nor peraws) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1 ,TX /'oma 7 $ 100 c� B. Conditionally Exempt-Specifier) Wastestream (Form DTSC 7�� EC 2 9 993 $ 100 C. Conditionally Authorized (Form DTSC 1 72C) °'`; $1,140 �aM1� g c,p,,., Ub D. Permit by Rule (Form DTSC 1772 $1,140 Account`o9 _________ Total Number of Units Total Fee Attached $ QUO ��oo H. GENERATOR IDENTIFICATION EPA ID NUMBER CAS q-Z 3�L (> Z s Zi BOB NUMBER (if available) H_HQ________ NAME (Company or Facility) -j' 7 D C.<7.0n/ �73 (DBA—Doing Busineu Ac) PHYSICAL LOCATION ZdA YOPt SS S/�O �,tiT'e SnoP ZSS 41AA::r L For DTSC Use Only CITY l�C /ro, CA ZIP Is 1-7 r Region COUNTY �/qn/ vA)A G Cx ln/ CONTACT PERSONM H011A10� PHONE NUMBER Z( d ) `/76 - (,Y4-) (Pvst Name) (last Name) DTSC 1772 (1/93) Page 1