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Slate y(Cali(oraia-Caiifor,"Eoviroameotal Proin Agency, Department o(Toaie$ubstaoces Cootxoi <br /> Ch«k Number 1 �./ �D� Page I of 9 <br /> aL- 82 00043 �'� <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORMC <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment ® Initial <br /> Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> C <br /> t Please refer to the attached Instructions before completing this form. You may norms for more than one permitting tier by using this <br /> I notification form,DTSC 1772. You must attach a separate unit specific notification form for each unit at this location There are <br /> different unit specific not fcationforms for each of thefour categories and an additional notificationform for transportable treatment <br /> units (ITU's). You only have to submit forms for the der(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 ITER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT 5 timer$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 specific notification forms you must attach. <br /> Conditionally Exempt Small Quantity Treahnent operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (not per wit) <br /> A. X Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. Conditionally Exempt-Specifi �ancas C rmDTSC 1772B) $ 100 <br /> C. Conditionally Authorized }m`\ooCo DTSC 1772C) $1,140 <br /> o _o <br /> D. Permit by Rule ~w' APRP� s� (F-b& TSC 1772D) $1,140 <br /> 93 <br /> 1 Total Number of Units "Niq�».,,,, Total Fee Attached $ 100 .00 <br /> 0 <br /> II. GENERATOR IDENTIFICAT 4c9gUENTo <br /> EPA ID NUMBER CA ____ BOE NUMBER (if available) Hy HQ_3 L DD_J183 <br /> NAME (Company or Facility) NCPA I.(TT)T (_AH TITRRTNP <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 2131 WEST 'TURNER ROAD <br /> For DTSC Use Only <br /> CITY LODI CA ZIP 95240 - <br /> Reaion <br /> COUNTY SAN JOAQUIN <br /> CONTACT PERSON MIKE ARGENTINE PHONE NUMBER 9C 16 )645 - 9170 <br /> (Fitrt Num) (Ian Name) <br /> DTSC 1772(1/93) U/;t �,p� _ Gam \ Pap 1, <br />