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State of CaaYoroia-Calit'oryle Environments rtectioo Agency Department of Toxic Substances Control <br /> - <br /> �Gheck tuber C / l7 �/ Page 1 of;Y <br /> t --- g2 0002. 6 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> v For Use by Hazardous Waste Generators Performing Treatment ❑ Initial <br /> Under Conditional Exemption and Conditional Authorization, <br /> ❑ Revised <br /> y and by Permit By Rule Facilities <br /> C <br /> y Please refer to the attached Instructions before completing this form. You may notes for more than one permitting tier by using this <br /> notification form, DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for each of the four categories and an additional notificationform for transportable treatment <br /> units (77T1'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 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 /> (Please 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, NOT 5 timer$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe$2,280.) Checks 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 box above. <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 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 Fee per Tier <br /> (not per wit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC I772A) $ 100 <br /> B. _X Conditionally Exempt-Specified Wa (Form DTSC 1772B) / $ 100 <br /> C. Conditionally Authorized ren DTSC 1772C) $1,140 <br /> D. Permit by Rule `}" Vo DTSC 1772D) $1,140 <br /> NA,PR011993 =� <br /> Total Number of Units C Total Fee Attached $ Co.W <br /> of iia Depaemanl ea <br /> of Health Sanioes <br /> H. GENERATOR IDENTIFICATION SgoH too <br /> EPA ID NUMBER CAL g;L L QQ/ ��s BOE NUMBER (if available) HEHIZ j�joCaS 1 <br /> �[ <br /> NAME (Company or Facility) _ a_Q �P .4_ H9,7 ( 0-nt0 X-" <br /> (DBA—Doing Business As) r ' ^ <br /> PHYSICAL LOCATION 5 CO eG . <br /> c 1_ For DTSC Use Only <br /> CITY may( U��C [�t� CA ZIP C�Sa�� <br /> Region <br /> COUNTY ��/1 Yl 1TL-Y-1 11A I I x'-1 <br /> CONTACT PERSON +,/ � J-p, PHONE NUMBEQ�-j 00�) <br /> (Fire Name) Name) <br /> DTSC 1772(1/93) � P I <br /> sAc L-,L.t� C �` (:.o fl LIT!.i 1)�' '� : I / W q, <br />