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Page Numoer ,k of ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment f3 Initial Under Conditional Exemption and Conditional Authorization, ❑ Revised y and by Permit By Rule Facilities Please refer to the attached Instructions before completing this form. You may not fy for more than one permitting tier by using this nonficaiion form, DISC 1772. You must arrach a separate unit specific notification form for each unit at this location. There are different unit specific norificarion forms for each of the four categories and an additional notfication form for transportable treatment units (77U's). You only have to submit forms for the tiers) that cover your unit(s). Discard or recycle the other unused forms. ,Number each page of your completed notification package and indicate the total number of pages at the top of each page at the 'Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested. all fields must be completed except those that state 'if different' or 'if available'. Pleare type the information provided on this form and any attachments. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that the fee it per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, you on/v owe 51.140, NOT S tinea Sl,14a If you operate any Permit by Rule units and any units under Coriditional Authorization you owe 52,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please wrire your EPA m Number on the check Fill in the check number in the box above. 1. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unitspecific notification forms you mutt attach. Conditionally ExaNx Small Quantity 76eamtost opaationa may tsar opo+ett units rude any odAe tie. Number of units and attached unit specific notifications Fee per Tier ria par watt A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. Conditionally Exempt-Specified Wastestteam (Form DTSC 1772B) S 100 C. Conditionally Authorized (Form DTSC 1772C) 51,140 D. Permit by Rule (Form DTSC 1772D) 51,140 Total Number of Units Total Fee Attached S H. GENERATOR 11DENTIFICATION EPA ID NUMBER CAL Q D -L j 1 BOE NUMBER (if available) H_HQ__ _ __ _ _ _ NAME (Company or Facility) LONGS DRUG SPORES CALIFORN f A - INC ,DBA—Doing Buuneu As) PHYSICAL LOCATION LONGS DRUG STORES # 14:1 4113 uaa� l.�,IGes �r�o �l� y For DTSC Ur Onit CITY 3T1X1.�6(� CA ZIP g5a01 section COUNTY n CONTACT PERSON NANOY crtruTnFu PHONE NUMBER( 510) 210- 6625 (Firm Nm) (las Nurrl DTSC 1772 (1/93) Page I