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57akatCalifanis -Califoron Protection agency Departmet of Toric Subeunces Contrd <br /> Cbeck NumberCid D Page I of <br /> �56 do 76Go J j 3 0 0 T8 <br /> v ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Perforating Treatment 10 Initial <br /> ,(Y3 Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> 41 and by Permit By Rule Facilities <br /> y Please refer to the attached Instruesions before completing this form. You may notify for more than one permitting tier by using this <br /> not fication form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific not fication forms for each of the four categories and an additional not ficationform for transportable treatment <br /> units (77U's). You only have to submit fortis for the tier(s) that cover your unit(s). Discard or recycle 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 /> (Pleats note that the jet 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 dma$1,140. lfyou operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe$2,280.) Cheats 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 /> L NOTIFICATION CATEGORIES <br /> Indicate the mmnber of units you operate in each tier. This will also be the number of unit specific notification forms you must attach. <br /> ('awdlNowally Eump iSnlnII Qumttity T reaanent operatiow may not operate unity under any outer tier. <br /> Number of omits end attached unit specific ratifications Fee per Tier <br /> (nor 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 /> PE'EIVED Bf: <br /> D. Per by Rule fivnrdcr Waste Manag, Form DTSC 1772D) $1,140 <br /> 7SEP . i993 loo.00 <br /> _Total Number of UnitsTotal Fee Attached S <br /> IT OF TOXIC <br /> IL GENERATOR IDENTIFICATI N rordrr oI- <br /> EPA ID NUMBER CA D981163967 ___ _ _ BOE NUMBER (if available) H Y HQ 36011341 <br /> NAME (Company or Facility) Tri Valley Growers <br /> (DRA—Doing lattices Aa) <br /> PHYSICAL LOCATION Plant T <br /> 26200 Nowell Road <br /> For DTSC Use Only <br /> CITY Thornton CA ZIP 95686 _ <br /> Rasion <br /> COUNTY San Joaquin <br /> CONTACT PERSON Chris Dozier PHONE NUMBER2( 09 ) 794 2303 <br /> (Fit Name) (Lax Name) <br /> DTSC 1772 (1/93) �J kLjD' r—L Page 1 <br />