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State of California-CaBfornla Barin ental ' lection Agency Deparemont of Tone Srrbataoces Co <br /> Page 1 off 1 1� <br /> Chwk Number <br /> 131 <br /> g2 0001 3 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment initial <br /> UUnder Conditional Exemption and Conditional Authorization, ❑ Revised <br /> y and by Permit By Rule Facilities <br /> r <br /> C <br /> h Please refer to the attached Instructions before completing this form. You may notify jot more than one permitting tier by using this <br /> j notication form, DTSC 1772. You must attach a separate unit specific notification forst for each unit at this location. There are <br /> different unit specific notification forms for each of the four categories and an additional notifrcationform for transportable treatment <br /> units (TTU'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; allfields 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 S units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT 5 timers$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 speck noti ication forms you must attach. <br /> Condawnally Exempt Small Quantity Treatment operations may not operate unus ureter any other tier. <br /> Number of units and attached unit specific notifications Fee per Ties <br /> (rot per unit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC I772A) S 100 <br /> B. 2— Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> 2 Total Number of Units Total Fee Attached $100 <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 0 3 6 8 3 0 <br /> NAME (Company or Facility) FGL Environmental <br /> (DBA—Doing Busineu As) <br /> PHYSICAL LOCATION 2500 Stagecoach Road <br /> For DTSC Use Only <br /> CITY Stockton CA ZIP 95215 _ n <br /> Region �1-- <br /> COUNTY San Joaquin <br /> CONTACT PERSON John Quinn PHONE NUMBER 2( O9 ) 942 -0181 <br /> (Firat Name) (LAu Name) <br /> DTSC 1772 (1/93) Page I <br />