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.Cate of Lautornia-California Earironmental Protection Agency Department of Toxic Substance Control, <br /> Check.Number _ Page 1 Of_/ <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM . <br /> FACILITY SPECIFIC NOTIFICATION <br /> 3 For Use by Hazardous Waste Generators Performing Treat(((///trnnlent-, Initial <br /> U gl211 o)b 13'6' Under Conditional Exemption and Conditional Authorizat on AUG2 ti.31 Devised <br /> and by Permit By Rule Facilities <br /> s � <br /> h Please refer to the attached Instructions before completing ihisjorm. You may notifyfor more than one permitting tirn by using this <br /> notification form, DISC 1772. You must attach a separate unit spec fc notification form for eacG�unir'drthis locatloh. There are <br /> different unit specific nor(cation forms for each ofthefour categories and an additional not fcationforrri for transportable treatment <br /> units (7711's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or rerycle 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 will not be considered complete without payment of the appropriate fee 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. !f 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 m Number on the check. Fill in the check number in the box above. <br /> I. NOTIFICATION CATEGORIES <br /> indicate the number of units you operate in each tier. This will also be the number of unit spec fc not f cation forms you must attach. <br /> Conditionally Ewrtpt Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (not per unit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> - B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> Total Number of Units Fi(IZt tGt yr.,tTotal Fee Attached $ <br /> R. GENERATOR IDENTIFICATION / <br /> EPA ID NUMBER CAL Q t3 Q 1. SS .2 S j T BOE NUMBER (if available) H_HQ__ _ _ _ _ __ <br /> NAME (Company or Facility) Uz C A n E KA 67-2- <br /> (DBA—Doing Businem Aa) <br /> PHYSICAL LOCATION _3zoo <br /> Ao ge d <br /> � 25� <br /> CITY 7 For DTSC Use Only <br /> CA ZIP '95376- <br /> COUNTY C, Region <br /> 0..✓� 700.L700.c�ti,�_ <br /> CONTACT PERSON E. 4f0 All d MAS PHONE NUMBERZO S5� - ®` 7/ <br /> (Fire Nsme) (tJLt Name) <br /> DTSC 1772 (1/93) Page I <br />