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• Stateofh.:ahfOrnu-CahfOnliaFat-r,iroomeotah Fratecaao Agency Department t r Toa Jobst ca Control <br /> Chock Number pv s Pt,;e I of 3 <br /> v <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORK, <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 /> Please refer to the attached Instructions before completing this form. You may noth for more than one pen sitting tier b j using this <br /> notication form, O7SC 1772. You must attach a separate unit specific notificationform for each unit at Ills location. There are <br /> different unit specific notifhcation forms for each ofthefour categories and an additional nothcationform for transporrabl r treatment <br /> units (ITV's). You only have to submit forms for the tier(s) that coat your unit(s). Discard or recycle the other um red forms. <br /> Number each page of your completed notification package and indicate the total number of pages at the tort of each pa/a at the <br /> Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested; all fiel Is must be <br /> completed except those that state 'if different' or 'if available'. Please type the information provided on this for, h and any <br /> attachments. <br /> The notification will not be considered complete without payment of the appropriate fee for each tier under v hich you arc operating. <br /> (Please note that eve fee is per 77ER not per UNIT: For example, ifyou operate S units but they are all Conditionally Authorized, <br /> you only owe 51,140, NOT S timer SI,I4a If you operate any Permit by Rule units and any units under Conditional At"horization <br /> you owe$2,280.) Chucks should be made payable to the Department of Toxic Substances Control and be s 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 /> 1. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific noticatio.s forms you h, test attach. <br /> Conditionally Exempt Small Quantity Treatment operations may not operate units under any other her <br /> Number of units and attached unit specific notifications Re per Tier <br /> V Gi at0,0Ow per wat) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 177 Pad r ai Oo°,me �. $ 100 <br /> B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 17 B) ✓f/N $ 100 <br /> C. Conditionally Authorized (Form DTSC 17 C) Sopa $1,140 <br /> D. Permit by Rule (Form DTSC 1772 eo u Q °h J $1,140 <br /> w <br /> 1 Total Number of Units Total Fe,a 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 Business As) <br /> PHYSICAL LOCATION Central Cellars <br /> 1 Winemaster's"Way <br /> —_ For Irl SMumordy <br /> CITY Lodi CA ZIP 95240 - <br /> Regior <br /> COUNTY San Joaquin <br /> l` CONTACT PERSON Vernon DeWulf PHONE NUMBER 2( 09 ) 368 _ 5151 <br /> (Fra Name) Nat Name) <br /> DTSC 1772 (1/93) Page I <br />