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Sun e!California-California Favirm 1 Protection Agency Departaaeat of Toac sewtaocei CON&W Clu,ct umbo Page I of ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION APP D 2 Ia13. For Use by Hazardous Waste Generators Performing Tresttneat Initial LNVIRQNMENTAL 11FALTPfer Conditional Exemption and Conditional Authorization, ❑ Revised IT PEFRP01 VSF /'rFt ,, and by Permit By Rule Facilities Please refer to the arrached Instructions before completing this form. You may noth for more than one permitting tier by using this nothcation form, D7SC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific notification fonts for each of the four categories and an additional notificationform for transportable treatment units (TTV s). You only have to submit forns for the tiers) 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 pager 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 availabk'. Please type the information provided on this form and any artachments. 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 S units but they are all Conditionally Authorized, you only owe$1,140, NOT S timer$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 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 atrach. Conditionally Exempt Small Quantity Treatment operations may not operate units wuler any other tier. lumber of units and attached unit specific notifications Fee per Tier (not per wit) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 C. Conditionally Authorized (Form DTSC 1772C) $1,140 D. 1 Permit by Rule (Form DTSC 1772D) $1,140 1 Total Number of Units Total Fee Attached $ IL GENERATOR IDENTIFICATION EPA ID NUMBER CA QQ Q 12 L_ -Z _L57 0 Z BOE NUMBER (if available) HYHQj k 12 O .& _Z j6l— NAME (Company or Facility) 5AA`t ' "" COMP Vif (DBA—Doing Busincu As) PHYSICAL LOCATION 5-1oLK%ON PAR.VT 35-/S N/wy DatuE For DTSC Um Only CITY 5r DGiCroA/ CA ZIP o/ Region 'OUNTY SAN JoAQyiA/ CONTACT PERSON DONALD IaGMlt hN*6pr PHONE NUMBER(Zy x.10 -3.39j (First Name) (Last Name) Page 1 DTSC 1772 (I/93)