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State of California-California Environmena`,,;otection Agency „J Department of Toxic Substances Control <br /> Page 1 of 9 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOAMO1-FORM <br /> FACILITY SPECIFIC NOTIFICATION ❑ Initial <br /> For Use by Hazardous Waste Generators Performing Treatm"L ® Amended <br /> Under Conditional Exemption and Conditional Authorization, <br /> and by Permit By Rule Facilities ENVihi,,.,.,-.. <br /> PERMIT/SERVICES <br /> Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> notification form, DTSC 7772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms forfive of the categories and an additional notification form for transportable treatment units <br /> (ITV's). You only have to submit forms for the tier(s)lcategory(ies) that cover your unit(s). Discard or recycle the other unused <br /> forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at <br /> the '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 highest tier the notifier will operate under and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE PAYMENT 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 notification forms 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. 1 Conditionally Exempt-Small Quantity Treatment (CESQT) D. _ Permit by Rule (PBR) <br /> B. _ Conditionally Exempt-Specified Wastestream (CESW) E. _ CE--Commercial Laundry (CE-CL) <br /> C. Conditionally Authorized (CA) F. Conditionally Exempt-Limited(CEL) <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA L 9 2 3 0 4 3 6 7 0- BOE NUMBER (if available) HY HQ3 6 L3 6 8 3 0 <br /> FACILITY NAME FGL Environmental , Inc. <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 2500 Stagecoach Road <br /> CITY Stockton CA ZIP 95215 - <br /> COUNTY San Joaquin <br /> CONTACT PERSON Roger Perry PHONE NUMBER 8( 05 )659-0910 <br /> (First Name) (Last Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME FGL Environmental <br /> STREET P. 0. Box 272 <br /> CITY Santa Paula STATE CA ZIP 93061_ <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON Roger Perry PHONE NUMBER 8( 05 ) 659-0910 <br /> (First Name) (Last Name) <br /> DTSC 1772 (1/96) Page 1 <br />