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30111110at.aaramu - t:aaforaaa 11,11 m-UW rMtKt1ou Agency uetwrtmem of lone �utaaaacn Lo,trfe <br /> Chock Number Page l of 7 <br /> v ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> r' FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Perforating Treatment Initial <br /> Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> ,a�CQ and by Permit By Rule Facilities <br /> y" Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> E notification form, D7SC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notication forms for each of the four categories and an additional notificationform for transportable treatment <br /> units (=s). You only have to submit forms 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 ercept those that state 'if different' or 'if available'. Please type the information provided on this form and any <br /> attachments. <br /> The notlJication will nen be considered complete without payment of the appropriate fee for each tier under which you are operating. <br /> ITIcase note that the fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, IVOT5 Nino.$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe$2,280.) Chectr 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 ID Number on the check Fill in the check number in the bot above. <br /> L NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notificationforms you must attach. <br /> CawdbionaQy Bvenpe Small Quantity 7)emment operations may not operate wits order any odaer her <br /> Number of units and attached unit specific notifications Fee per Tier <br /> root per unit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. 1 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 /> 1 Total Number of Unita Total Fee Attached S 100.00 <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA D981163967 BOE NUMBER if available H Y HQ.36011341 <br /> NAME (Company or Facility) Tri Valley Growers <br /> (DRA—Doig B limes An) <br /> PHYSICAL LOCATION Plant T <br /> 26200 Nowell Road <br /> r,-...y <br /> TSC Use Only <br /> CITY Thornton CA ZIP 95686 _ <br /> COUNTY San Joaquin <br /> CONTACT PERSON Chris Dozier PHONE NUMBER2( 09 ) 794 2303 <br /> (Fin Name) (t&n Name) <br /> DTSC 1772 (1/93) Page I <br />