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ware or r.aworuu-California EtritonmeoLal Protection Ali n y Department or Toxic Substance Coo Chat Number Page I of_ ONSITE HAZARDOUS VG T&EAt II NOTIFICATION FORM FACILITY SPECIFIC }1($TIFICATION 3 For Use by Hazar&Wk9a2te GP*rWor j Serforming Treatment Initial U Under Conditional Exemption and Conditional Authorization, ❑ Revised v and by Permit By Rule Facilities i r 5 Please refer to the attached Instructions before completing this form. You may norms jar more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specfc notification form for each unit at this location. There are different unit specific notifcationforms for each of the jour categories and an additional notif cationform for transportable treatment units (TPU'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 jar each tier under which you are operating. (Please note that the fee is per 77ER not per UNIT. For example, ifyou operate S units but they are all Conditionally Authorized, you only owe$1,140, NOT S times$1,140. Ifyou 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 notfcation forms you must attach. Conditionally Exempt Small Quantity Treatment operations may not operate unify under any other tier. Number of uniLs and attached unit specific notifications Fee per Tier (not per unit) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. Conditionally Exempt-Specified Wastestream (Form DTSC I772B) y 100 C. Conditionally Authorized (Form DTSC 1772C) $1,140 D. Permit by Rule (Form DTSC 1772D) $1.140 Total Number of Units Total Fee Attached S 11. GENERATOR IDENTIFICATION / EPA ID NUMBER CAL -0 p Q-L 9 7 S$ T BOE NUMBER (if available) H_HQ_ _ _ _ _ _ _ _ NAME (Company or Facility) RAZ C A n E RA 4 22 (DBA—Doing Busineu As) PHYSICAL LOCATION -MOO $ , 6/A Q Le e cITY CA zip g53 � ZSR For DTSC Use Only T2,ac./ 76- Region COUNTY a n 700.� CONTACT PERSON E. 6-O Al T_L/1 el( ,4 PHONE NUMBERZO?)S5i6 - 0171 (Fire Neme) (Lau Narnc) DTSC 1772 (1/93) Page I