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t 51ale K California-California Environments; iecdon Agency <br /> Deparfinem of'roxic Substances Control <br /> Page 1 of-7 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFIC ION DEPARTMENT Df <br /> For Use by Hazardous Waste Generators Perf <br /> tt <br /> ANC S C!7h - Initis] <br /> Under Conditional Exemption and Conditional , I Amended <br /> and by Permit By Rule Facilit 31( <br /> Please refer to the attached Instructions before completing thisform. You may notificationform, DISC 1772. You mast attach a separate unit s ecic roti P 6M) minting tier by using this <br /> different unit specific notificarion fon. There are <br /> rms for five of the categories and an additional notification form four traruportablet at this ttreatment units <br /> (ITU's). You only have to submit forms for the tiers)/category(ies) that cover your unit(s). Discard or recycle the other unused <br /> forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at <br /> the '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 fees are assessed on the basis of the highest tier the notifier will operate under andwill be collected by <br /> the State <br /> Board of Equalization. DO NOT SENU YOrili FEE PAYMENT WITS :HIS NOTIFICA;iJ v etih M. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you <br /> must attach. Conditionally Exempt Small Quantity Treatment operators may not operate units under any other tier. <br /> Number of units and attached unit specific notifications for each tier reported. <br /> A• — Conditionally Exempt-Small Quantity Treatment (CESQT) D. permit by Rule (PER) <br /> B. I Conditionally Exempt-Specified Wastestream (CESW) E. CE--Commercial Laundry (CE-CL) <br /> C• Conditionally Authorized (CA) F. Conditionally Exempt-I..'mired (CEL) <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA_2 j2.Q m m 3 3 6 ( BOE NUMBER (if available) H_HQ_— —__ <br /> FACILITY NAME WOl F ('LI�IE/>'At 9� <br /> (DBA-Doing Business As) /+ <br /> PHYSICAL LOCATION S O 0.L)TI G AV 6 <br /> CITY STOU<i ON CA zlrs $207_ <br /> COUNTYN <br /> CONTACT PERSON SCOL- \&/fnfl ty)g__ _1HJNENUMBER 8( 88 )206 - Z04-2 <br /> - <br /> (NM Namr) (list Name)J <br /> MAILING ADDRESS, IF DIFFERENT; <br /> COMPANY NAME Iil/OL� 11 <br /> STREET Zti�K_ <br /> CITY A f�Qr7 f� _ <br /> STATE GA ZIP <br /> COUNTRY <br /> CONTACT PERSON (oNy comPletc if not USA) <br /> 'HONE. NUMBER(" tSIS� _ ,9pGt� <br /> (First Name) R ast Nan <br /> DTSC 1772 (1/96) <br /> Page I <br />