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,, Yee Of Califurnu CaLturuia Fa,imnmmW t'n„w•.••o AVmx + Departmosl of Toxic Su e0arwC"In11 <br /> lwct )Tumhn CiO.P' G Page I OI <br /> 0 4110 •..( <br /> ONSITE HAZARDOUS WASTE; THEA NIEN47 NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> "` Fur Use hs Hazardous \baste Generalot. Periorm ing Treaimrni ❑ Initial <br /> VUndri Conditional Exemption and Conditional Authorization. ❑ Rcvix•J <br /> and by Permit By Rule Facrhtins <br /> c <br /> t7; Plea,r refer to the attached Instructions before completing this form. )'ou may wtrfy for more than one permitting tier by using this <br /> notification form. DTSC 1772. )'ou must attach a separate unit specific notification form for each unit at.this location. There are <br /> different unit spen(e notiri canon firms for each of the four categories and an additional notieationform for tranrporrable treatment <br /> units (77V 3) You onA have to subnut forms for the uer(s) that msrr your unit/s). Discard or rerycle the other unused forms <br /> Number each puge of your completed notification package and indicate the total number of pages at the top of each page ar the <br /> Take — of_ ' Pw o,r FRA ID Number on each page Please provide all of the information requested: all fields must he <br /> completed ucepr Moir that stair 'if d�flerenior 'if available'. Please nPe the information provided on this form and am. <br /> attachment. <br /> The notification will cat be consdered complete without payment of the appropriate fee for each tier under which you arc operartng <br /> (Please note that the fee t per TIER not per UNIT. For euample, if you operate S units but they are all CondinionallyAuthon;rd, <br /> you only owe 51,140, NOT S tuna $1,110. If you operate any Permit by Rule units and acv units under Conditional AuhoriZmion <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 /> Jam. 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 noricationformr you mutt attach <br /> Condirlonally Exempt Small Quaruiry Treatment operarions may nlor operate units urdo any other tier. <br /> Number of units and attached unit specific notifications Je Service Fee per Tier <br /> ��pty Ogeratlone4' mot per am: <br /> A. Conditiogally Exempt-Small Quantity Treatment (Form DTSC 1772A) ,may �� aO S 100 <br /> B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) QLL 6 1993 $ 100 <br /> OCT <br /> C. /K <br /> ` Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> rimer r Toric <br /> D. Permit by Rule (Form DTSC 1772D) S1,140 <br /> Toul Number of UoiLs Total Fax Attacbed S ( ' ) <br /> 11. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA19' Gni a-0 D BOE NUMBER (if available) H_HQ_ _ _ _ _ _ _ _ <br /> NAME (Company or Facility) f�FT1vrL1 U 4 <br /> (DBA—Doing Bueueae Aa) <br /> PHYSICAL LOCATION I 0C) �:'P"S I I N P0­4 <br /> For DTSC Ur ONy <br /> CM, 1 D J N CA z1P 3 jo c, <br /> �r Rraion <br /> COUNTY <br /> CONTACT PERSON �FoR U PHONE NUMBERC , )Sei <br /> (fur Now) (las Nem.) <br /> DTSC 1772 (1197) UALL�J�,_) <br />