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State of California -California Fnrirour i Pmtection agency f Toldc Subaraoee Conumi <br /> Check Number �-- EI ' �"'e'I Page 1 of 7 <br /> 16350 MAR 16 1993 <br /> ENVIRONMENTAL HEALTH <br /> ONSITE ILA.ZARDOUS WASTE TREATINIEW-NOMTO `SON FORNI <br /> FACILITY SPECIFIC NOTIFICATION <br /> 1 <br /> For Use by Hazardous Waste Generators Performing Treatment ® Initial <br /> J Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> C <br /> iy Please refer to the attached Instructions before completing this form. You may notify far more than one permitting tier by using this <br /> 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 notification foams for each of the four categories and an additional noticationform for transportable treatment <br /> units (777J 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 appropriare fee for each tier under which you are operating. <br /> (Please note that rhe fee is per 77ER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> you only owe 31,140, NOT S times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe 32,280.) 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 Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (not per=r) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. 1 Conditionally Exempt-Specified Wastestream (Form bTSC 1772B) $ 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 $ 100.00 <br /> H. GENERATOR IDENTMCATLON <br /> EPA ID NUMBER CAD 1 1 5 0 9 2 0 2 5 BOE NUMBER (if available) HA HQ 3 6 0 4 5 4 2 7 <br /> NAME (Company or Facility) Van den Bergh Foods Company <br /> (DBA—Doing Business Aa) <br /> PHYSICAL LOCATION 1400 Waterloo Road <br /> For DISC Use Only <br /> CITY Stockton CA ZIP 95205 - <br /> Region <br /> COUNTY San Joaquin <br /> CONTACT PERSON Frank Yoneshige PHONE NUMBER 2( O9 ) 466 - 9580 <br /> (Fire Name) (Last Name) <br /> DTSC 1772 (1/93) Page 1 <br />