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Stns of Catifo -Ca6foraua Ea�e W Vection Agency J�u �;J Deprruemt of Tone Suintaoes Cmud <br /> cacti Namoer JUN G 3 1994 Page I of Z <br /> ENVIRONMF " ):ALTH <br /> ONSITE HAZARDOUS WASTE Tf&Ath1tN1r NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment ® Initial <br /> V Under Conditional Exemption and Conditional Authorization. ❑ Revised <br /> C and by Permit By Rule Facilities <br /> a <br /> y 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, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for each of the four categories and an additional notification form for transportable treatment <br /> units (=s). You only have to submit forms for the tiers) that cover your unii(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 stare '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 TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT S 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 specific notification forms you must attach. <br /> CondudorutHy Exempt Small Quantity Treatment operations may not operate unit under any other tier. <br /> Ntmnber of units and attached unit specific notifications Fee per Tier <br /> (rot per unit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 <br /> B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) S 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> 1 Total Number of Units Total Fee Attached S-0.00 <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA C 0 0 0 2 4 1 7 4 5 BOE NUMBER (if available) H_HQ3 6 0 3 4 2 2 2 <br /> NAME (Company or Facility) SEBASTIANI VINEYARDS <br /> (DBA—Doing Butimm As) <br /> PHYSICAL LOCATION 4614 W. TURNER ROAD <br /> CITY LODI CA ZIP 95242 For DTSC Uu Only <br /> Region <br /> COUNTY SAN JOAQUIN <br /> CONTACT PERSON DAVE HENRY PHONE NUMBER 2( 09 )339 - 1311 <br /> (Firs Name) (Lav Name) <br /> DTSC 1772 (1/93) Page 1 <br />