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dote of Califonyo.Catiforno Eos Mix"aonl^vsttaioo Agimv <br /> Delaulto t of Tont Substwm r Cotstrol <br /> ONSITEPage 1 of <br /> HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment Initial <br /> Under Conditional Exemption and Conditional Authorization. — Amended <br /> and by Permit By Rule Facilities <br /> Please refer to the attached Instructions bef <br /> notification form. DISC 1772. you ore completing this form. You may norify for more than one permitting tier by using this <br /> different unit specific notificatication fomust attach a separate unit specific noriftcanon form for each unit at this,location There are <br /> must <br /> for five of the categories and an additional notification form for transportable treatment units <br /> (='s). You only have to submit forms for the tier(s)/categorv(ies) that cover your unit(s). Discard or recycle the other unused <br /> forms. Number each pa <br /> the 'Page ge of your completed notification package and indicate the total number of pages at the top of each page at <br /> _ 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 forth and any <br /> attachments. <br /> The notification fees are assessed on the basis of the highest tier the notifier will operate under and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE PAYMENT WrM THIS NOTIFICATION FORM. <br /> 1. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific noriftcarion farms 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. _ <br /> Perini[ by Rule (PBR) <br /> B. X Conditionally Exempt-Specified Wastestream (CESW) E. <br /> _ CE–Commercial Laundry (CE-CL) <br /> C. _ Conditionally Authorized (CA) <br /> F. Conditionally Exempt-Limited (CEL) <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA__L__D__Q_Q 1 4 3 8 6 2 BOE NUMBER (if available) H_HQ_ <br /> FACILITY NAME TONGS DBA—Dome Business As. DRUG STORES #109 <br /> PHYSICAL LOCATION 7464 PACIFIC AVENUE <br /> CITY STOCKTON CA ZIP 95207 <br /> COUNTY SAN JOAQUIN <br /> CONTACT PERSON RON COOPER <br /> PHONE NUMBER( 209 ) 951 8621 <br /> [First Name. 'Ust Name) -- <br /> MAILING ADDRESS, IF DIFFERENT:STORE MANAGER <br /> COMPANY NAME LONGS DRUG STORES CALIFORNIA, INC. <br /> STREET 141 NORTH CIVIC DRIVE <br /> CITY WALNUT CREEK STATE CA ZIP 94596 _ <br /> COUNTRY <br /> wnly complete.f not USA) <br /> CONTACT PERSON FL <br /> ANDES PHONE NUMBER( 510 210 - 6999 <br /> .Fun Name) (Last Name) <br /> ENVIRONMENTAL MANAGER <br /> DTSC 1772 (1/96) <br /> Page <br />