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dtq`p x <br /> State of California-California Farino� sal Protection Agency { Department of Toric SuhMaeces Control <br /> Cht.k NumCZat�tmr �.: . .o `i:°r. Page 1 of 10 <br /> 131 MAR 3 0 1993 <br /> ENVIRONMENTAL I1EALP4' <br /> ONSITE HAZARDOUS WASTE TRWATMENT-NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment Q Initial <br /> U Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> y and by Permit By Rule Facilities <br /> tl <br /> vy Please refer to the attached Instructions before completing this form. You may notes for more than one permitting tier by using this <br /> norication form, DISC 1772. You must attach a separate unit speck notication form for each unit at this location. There are <br /> different unit specific notication forms for each of thefour categories and an additional noticationform 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; 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 times$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 notificationforms you must attach. <br /> Conditionally Exempt SmaU Quantity Treatment operations may not operate units under any cher tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (nor per wit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 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 3- -2-a Q 4- Z 3 BOE NUMBER (if available) HY HQ3 6 0 3 L8 3 0 <br /> NAME (Company or Facility) FGL Environmental <br /> (DBA—Doing Busmas As) Stagecoach Road 2500 Sta <br /> PHYSICAL LOCATION 9 <br /> For DTSC Uw Only <br /> CITY Stockton CA ZIP 95215 _ <br /> Region <br /> COUNTY San Joaquin <br /> CONTACT PERSON John Quinn PHONE NUMBER 2( O9 ) 942 -0181 <br /> (Finn Nam) (IIn Name) <br /> DTSC 1772 (1/93) Page I <br />