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..,of C.Aforra-Canford"Ilrita•eraf Protection Agency .�CG Department of Tone Sabgarm Control <br /> Page I of <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION_FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> � ) For Use by Hazardous Waste Generators Performing Treatment ;..X, Initial <br /> Under Conditional Exemption and Conditional Authorization, x10 �enewal <br /> and by Permit By Rule Facilities ❑ Amendment <br /> ' r <br /> Please ri fcr to the anadted Instructions before completing this form. You may notify for more than one permitting tier using this <br /> notificationform, DISC 1771. You must attach a separate unit sperifte notifrcadon form far each unit at this Ipgat" n. There are <br /> different unit specific notification forms for each of thefour categories and an additional notification form for,trunifbdrtable treatment <br /> units (TTIh's). You only have to submit forms for the tier(s) that cover your unit(s). Discord`or reo,l_i-,flte'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 fees are assessed on the'basis of the number of tiers the notifier will operate under, and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE WITH THIS NOTIFICATION FORM <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific not fication forms you must attach. <br /> Conditionally Exempt Small Quantity Treatment operations 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 TreatmenpJD. Permit by Rule <br /> B. / Conditionally Exempt-Specified Wastestrea r � E. Commercial Laundry <br /> C. Conditionally Authorized �Yti i ,9 F. Variance (Section 25143) <br /> 11. GENERATOR/IIDEN/T�IFICATION <br /> EPA ID NUMBER CA ` Q �y� � BOE NUMBER (if available) H—HQ— <br /> FACILITY NAME � �JD(/JS (/2� �� <br /> (DBA—Doing Business As) /1 <br /> PHYSICAL LOCATION (;A <br /> SOS c/F/G WV /� <br /> CITYoG CA ZIP 'I,�, 07 - <br /> COUNTY �pn �101�vn� <br /> CONTACT PERSON th Vy P"(— PHONE NUMBER( ?AXi)4.77 - I <br /> (Firpt Name) (Lacs Name) <br /> 17E(L 1 S A rJ <br /> MAILING ADDRESS, IF D=RENT: <br /> COMPANY NAME ` <br /> STREET <br /> CITY STATE ZIP <br /> COUNTRY <br /> (oNy complete if not USA) <br /> CONTACT PERSON PHONE NUMBER( ) - <br /> (Fint Name) (Last Name) <br /> DISC 1772 (1195) TP-001 -A Page I <br />