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Stvt,.4 CaUgeoia-California En.i eota slim Agency Depar>msat of Toxic col,..•....,Cmud F—Cb---k:9----b--, -j Page I of 99 92 03035 ij ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION °y4J For Use by Hazardous Waste Generators Performing Treatment �� o Under Conditional Exemption and Conditional Authorization, ❑ Revised c and by Permit By Rule Facilities I Please refer to the attached Instructions before completing this form. You may notify 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 notification form for transportable treatment units (ITV's). You only have to submit forms 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 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 nor(cation 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 timer 51,140. 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 attach. Conditionally Fxempt Small Quantity Treatment openanons may not operate units under any other tier. lumber of units and attached unit specific notifications Fee per Tier (nor per unit) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. Conditionally Exempt-Specified�asgrstreamn ti(Form DTSC 1772B) $ 100 C. Conditionally Authorized �J °e Pimo(F.�Km DTSC 1772C) $1,140 >` DTSC 1772D) $1,140 D. Permit by Rule o . APR 0 { --- ___-- 11993 = w r --------_ n s 1 Total Number of Units a,ur..... o.,,,, Total Fee Attached 5 m U. GENERATOR IDENTIFICATION 04CRAMENI EPA ID NUMBER CAD Q Q O ,L,� O Z BOE NUMBER (if available) HYHQ,j k 12 O fQ NAME (Company or Facility) SH�°j ' ^'t eol)IPANfJ (DBA—Doing Busimu As) PHYSICAL LOCATION 5 0 c kr oti &Ary r 3s/5— /2,4V t For DTSC U.Only CITY 5ror-kadz CA ZIP F6201 - Region 'OUNTY SAN JDAQviA/ CONTACT PERSON IOAtAL.D C3,4MAr&h4A8ar PHONE NUMBER(ZT )3-20 -33&* (Fire Name) (tam Norm) Page 1 DTSC 1772 (1/93)