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State atcalifit:,._.•Ctrlifornia Fnvironmental'rrmeetion Ageo<Y nn� 1i'► -' Department of Tome Suhasoc a Co ouW Cheer Nuro`cr ' , L> ; Vt' ` Page 1 of_y 233 4-(0 92 0 0 0 0 4 ENTERED MAY 1 2 1993 y ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM '�-a FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment Initial J Under Conditional Exemption and Conditional Authorization. ❑ Revised y and by Permit By Rule Facilities i) Please refer to the attached instructions before completing this farm. You may notify for more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific notification forms far each of the jour categories and an additional notification form far transportable treatment units (77V s). You only have to submit forms for the tier(s) 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'. Please 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 is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, you only owe$1,140, NOT 5 timer$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe $2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA m Number on the check. Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you must attach. Conditionally Exempt Small Quantity Treatment Operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier (not per writ) A. 0 Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. 0 Conditionally ExempLm�mr tr a 'n (Form DTSC 1772B) S 100 nto:;, :r�rC. 0 Conditionally Author ' (Form DTSC t772C) 51,140 D. 1 Permit by RuleForm DTSC 1772D) $1,140 ;9g� s 1140 .00 Total Number of Uniarr,egr ) Total Fee Attached S ri eII. GENERATOR IDENTIFIC .0 EPA ID NUMBER CA D099952996 __ _ _ _ BOE NUMBER (if available) H AHQ 3 6 O 2 8 9 5 9 NAME (Company or Facility) RM-Holz , Inc. (DBA—Doing Busineu As) PHYSICAL LOCATION 1129 S. Sacramento St. For DTSC nOnly CITY Lodi CA ZIP 95240 Region COUNTY San Joaquin CONTACT PERSON Ted Cooper PHONE NUMBER( 209 )368 7171 (Firm Name) Nu Name)