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.7•Y�CV,l.Y,V\YY v.... .r.0vuu.v .,,.„.......y.—� Chad:Number — Page 1 of (Q ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION ��I� r For Use by Hazardous Waste Generators Performing Trea MJ Initial U Under Conditional Exemption and Conditional Authorization, APR 0 1 19930 Revised and by Permit By Rule Facilities � ENVIRONMENTAL HEALTH c Please refer to the attached Instructions before completing this form. You may notify for more F;RW�tE&VaweS��by using this notification form, DISC 1772. You must attach a separate unit specific norification form for each unit at this location. There are different unit specific notification farms for each of the four categories and an additional not ficationfornn for transportable treatment units (TTU's). You only have to submit forms for the tiers) that cover your unit(s). Discard or recycle the other unused forms. Number each page of your completed notification package and indicate the total number ofpages at the top of each page at the 'Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested, all fields must be completed except those that stare 'if different' or 'if available'. Please type the information provided on this form and any attachments. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that rhe fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, you only owe$1,140, NOT 5 times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA ID Number on the check Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you must attach. Conditionally Except Small Quantity Treatment operations may not operate units under any of tier. Number of units and attached unit specific notifications Fee per Tier (not per umr) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 C. _ Conditionally Authorized (Form DTSC 1772C) $1,140 D. Permit by Rule (Form DTSC 1772D) $1,140 Total Number of Units Total Fee attached S_/00 II. GENERATOR IDENTIFICATION EPA ID NUMBER CAD O Q a_L¢L (L1.9 BOE NUMBER (if available) HA HQ3 L.L g,2, 0 4 L NAME (Company or Facility) Owe-tis - TII IN -i c Glass Muc_. (DBA—Doing Business As) PHYSICAL LOCATION 1.4700 lx) . 71Z0-rg�D--T_SC Use Only CITY �TtrSit u CA ZIP 9637/ 'J COUNTY Toaa.nt[u CONTACT PERSONPHONE NUMBER ,� 734-1r.a76 (Fim Name) (Lu Nam) DTSC 1772 (1/93) Page 1