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.— <br /> nt\I Ynlhfl Page I 011i <br /> ' TKP+NLIA — � r< PoN <br /> ONSITE HAZARDOUS WASTE TREA1 111•:;NT 51011MCiA,T ij`TT jORAl <br /> FACILITY SPECIFIC NOTIFICATION Fir' <br /> Fin k;w hs Hatlyd,,us Waatc Generator. I'erlornur 13Inuiel PM 2: 13 <br /> v <br /> Undet Conditional Exemption and Conditional Authorization. El Heviv,l <br /> .0 <br /> and by Permit By Rule Facthims <br /> N; Please refer it, the attached Innruntunt before completing this jorrn. You may nark for more than one permuting tier by ruing On, <br /> notification form. DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> diflerent unit sprrtftc nonirntion forms for each of the four categories and an additional norificasion form for transportable treatment <br /> urau t7TUb1. You one% have to subnna forms for the iter(s) that corer your utnr(s). Discard or retvcle the other unused fomu <br /> Number each pagr of your completed nouftcatton package and indicate the total number of pages at the top of each page as the <br /> 'Pat,•e _ of _' j',•r roar FI'.1 IfI N',mher on each page. Please provide all of the infurmatron requested. al!fields must h, <br /> completed ucept their that stair 'if dtperent' or 'if avatlablr'. Please ape the information provided on this form and ani <br /> attachments. <br /> The notification will oar be considered complete without payment of the appropriate jee for each tier under which you are operattnc <br /> (Please note that the fee u per TIER not per UNIT For example, tf you operate S units but them <br /> v are all Condirnalfv Aurhonzr <br /> you only owe $1.140, NOT S rima 1j 51,110. you operate any Permit by Rule units and anv units under Conditional Aushornarum <br /> YOU owe 12,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of tht, <br /> form. Please write Your EPA ID Number on the check. Fill to 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 notificationforms you must attach <br /> Conditionally Exempt Smell Quanary Treatment operations may rot operate units under any other tie. <br /> Number of units and attached unit specific notifications Fee per Ticr <br /> (rot per un.: <br /> A Condstiogally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C X Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D Permit by Rule (Form DTSC 1772D) 51,140 <br /> Total Number of Units Total Fee Attached S 1 ( ..t <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA-11L-2-2 t J �� D I BOE NUMBER (if available) H_HQ_ _ _ _ _ _ _ _ <br /> NAME (Company or Facility) orG��1 `� �UEY1 llot <br /> PHYSIICOA,L LOCATION I go <br /> LFor DISC Um Only <br /> CITY ' 1 1 fl� 1 I CA ZIP 3 • 0� <br /> _T Rgfon <br /> COUNTY Sfr� \ g.r-1QU1,1 <br /> CONTACT PERSON (--v� I ok PHONE NUMBER) 2T1- y I <br /> (Firs, Name) (tau Name) <br /> DTSC 1772 (1/93) Page I <br />