Laserfiche WebLink
Cltece Number V• W,y��W ••V�yVY� Page 1 of /g <br /> 198► o e ` O i' <br /> 92 0 0 35 .r <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> 't For Use by Hazardous Waste Generators Performing Treatment ® Initial <br /> V <br /> UUnder 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 notify for more than one permitting tier by using this <br /> notificarion form, DISC 1772. You must attach a separate unit specific norifrcation form for each unit at this location. ]here are <br /> different unit specific notification forms for each of rhefour categories and an additional notificationform for transportable treatment <br /> units (CPU's). You only have to submit forms for the tiers) 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 far each tier under which you are operating. <br /> (Please note that the fee is per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT S times$1,140. /f 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 specifte notification forms you must attach. <br /> Conditionally Exempt Small Quantity Treatment operntio units under any other tier <br /> Number of tints and attached unit specific no ' ct�Rds" "' Fee per Tier <br /> do�e�e •�'�iu (not Per uNd <br /> A. Conditionally Exempt-Small qty Treatmeat (Fojriii SC 1772A) $ 100 <br /> B. �_ Conditionally Exempt-Specifi wastAR" 1 19a&rm D SC 177213) $ 100 <br /> California HeaiDepartment io TSC 1772 $1,140 <br /> C. Conditionally Authorized e( C) <br /> D. Permit by Rule 04OAAM010 ormDTSC 1772D) $1,140 <br /> Total Number of Units Total Fee Attached S-00 <br /> 11. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAL O 0 a_L 4�L 3 19 BOE NUMBER (if available) HA HQ L 0 ;�2, 0 4 L <br /> NAME (Company or Facility) Owe as - TIIiNcic Glass rlicwAa?uac Twit.. <br /> (DBA-Doing Business As) - - <br /> PHYSICAL LOCATION 14700 w _ <br /> For DTSC ZOnlyCITY Tv �rt, CA ZIP 9ss7// <br /> U Region <br /> COUNTY San; Tc-aa.t.titi) <br /> CONTACT PERSON �c �` TaIc+�I PHONE NUMBER(ELO )734-1ea7(� <br /> (Fin[Name) (Last Name) <br /> DTSC 1772 (1/93) Page 1 <br />