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�....., „n,.•a.aarorma1SaruvaIDmtatr to000Ageaty lhpartmeat((Toxic Sobse cn Ceotrot <br /> Cha Number <br /> P,,;e 1 of 3 <br /> IV <br /> ONSITE HAZARDOUSt;WrEEI PMATMENT NOTIFICATION FORM <br /> c7 Wy�t�,G p�g <br /> FA&mTY SPEC1Pic NOTIFICATION <br /> For Use by Harar�to(ars WistaGejetatats Performing Treatment ® Initial <br /> Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> i Please er to the attached Instructions t <br /> ref before completing this form. You may notes for more than one pm.tilting tier .) using this <br /> notification form, D7SC 1772. You must attach a separate unit specific notication form for each unit at Ois location.. There are <br /> different unit specific notification forms for each ofihefour categories and an additional nothcationform for tranrporiabl+treatment <br /> units (77V's). You only have to submit forms for the der(r) that corer your unit(s). Discard or recycle the other unt red forms. <br /> Number each page of your completed notification package and indicate the total number of pages at the toil of each pal a at the <br /> Page_ of_'. Put your EPA ID Number on each page. Please provide all of the information requested; all fief is must be <br /> completed except those that state 'if different' or 'if available', Please type the information provided on this for,i and any <br /> attachments. <br /> The notification will not be considered complete without payment of the appropriate fee for each tier under rich you art operating. <br /> (Please note that rat fee is per 77ER not per UNIT. For example, if you operate S units but they are all Conditionally lluthorited, <br /> you only owe$1,140,NOT5 times 51,140. If you operate any Permit by Rule units and any units under OmelitionalAi horization <br /> you owe 52,280.) Chucks should be made payable to the Department of Toxic Substances Control and be t tapled 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 notificatio.iforms you i, ust attach. <br /> Conditionally Exempt SmaU Quantity Treatment operarions may not operate unix undo any other tier. <br /> C Number of units and attached unit specific notifications F(a per Tier <br /> (-1M 600 <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. 1 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 /> I Total Number of Units Total Fes Attached <. 100.00 <br /> IL GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA L 0 0 0 0 2 4 1 6 0 BOE NUMBER (if available) H_HQ <br /> NAME (Company or Facility) Canandaigua Wine Co. _ <br /> (DBA—Doing Businen As) <br /> PHYSICAL LOCATION Central Cellars <br /> 1 Winemaster's Way <br /> For D SC Ute only <br /> CITY Lodi CA ZIP 95240 - <br /> _ Regina <br /> COUNTY San Joaquin <br /> CONTACT PERSON Vernon DeWulf PHONE NUMBER 2( 09 ) 368 _ 5151 <br /> (First Name) (lea Name) <br /> DTSC 1772(1/93) Page 1 <br />