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Styr of Cakferas•CAVeraa Earbwrmd Preasaaa ANq DIMuora of Trac Smemue w Cow <br /> r aaewr <br /> i .��gI6-7 Page IofIG <br /> i_ <br /> ONSITE HAZARDOUS WASTE TREATNIENT'NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTiFICATIOVI AL I <br /> For Use by Hazardous Waste Generators Perforot i Ti"61"ia-'•:; x <br /> Iatttal <br /> Under Conditional Exemption and Conditional Authorization, ❑ Rrvtsed <br /> and by Permit By Rule Facilities <br /> C <br /> D <br /> to Please refer to the arrached Instructions before completing this form. You may notify for more than one pernurting tier by using this <br /> I noriflcarion form, DTSC 1772. You must attach a separate unit sped fc notification form for each unit as this locarioi, 7herr are <br /> different unit specific notif icurion johns for each of the jour casegorier and an additional snob$icarion jorm jot trauportabletnarnre u <br /> umu (17U's). You only have to submit forms for the her(s) that cower yarn unit(s). Discord or recycie the ocher unusedforms. <br /> Number each page of your completed nosification package and indicate the total number of pages at the top of each page at he <br /> Page _ of_'. Put your EPA ID Number on each page. Plmu provide all of the infornwrion requested, aU fields mun be <br /> completed ercept thou that state 'ij different' or 'if avwlabie'. Please type the infomwtum provided on his form and any <br /> attachments. <br /> Thr notification will not be considered complete without payment of the aWropnare fee foe each tier under which you are operating. <br /> (Pleate hoe that thefee is per TIER not per UNIT: For aamPie, if you operme S units bin they art all Cowdlsionally Authorized, <br /> you only owe $1,110, NOT S dinar$I,l1a ((you operate any Permit by Rub midst and any units under Condisioro/Authorization <br /> You owe$2,21!0.) Checks should be made payable to the Department of Tame Subarannn Control and be stapled to the top of this <br /> form. Please wrue your EPA ID Number on the cheat Fill in the cheat number in the bare above. <br /> L NOTIFICATION CATEGORIES <br /> lndicase the number of umu you operate in each tier. This will alwo be the nwnber of umit sped$is mmiflcwion fomv you must attach. <br /> Cadirsowdh Exceir Sne ll Qumuiry Tr cower opermbns naay wow opffma main ads any admin tis. <br /> Number of units and attaehed unit speeifk ootiAcations Fee per Tier <br /> Mar M v ) <br /> A. Conditionally Exempt-Small Quantity Treatmew (Form DTSC 1772A) $ 100 <br /> B. L+ Conditionally Exempt-Specified Wauasttewm (Form DISC 1772B) f 100 <br /> C. Conditionally Authorimd (Form DTSC 17720 $1,140 <br /> D. Permit by Rule (Form OTSC 1772D) <br /> $1,140 <br /> 4 Total Number of Units ToW F« Attechtl S /DO - <br /> EL GENERATOR MEN InCATION <br /> EPA m NUMBER CA_QQ JS_____ BOE NUMBER (if available) H—HQ_______ <br /> NAME (Company or Feedity) b O ci-n r S N O Sci A a I 0-( <br /> 07L4–Deiaa b�N) <br /> PHYSICAL LOCATION 1 Z 0 S tV k 1 Sir r P1— <br /> P - 0 , l3oX 1 `tl <br /> . For D=Ur(>dt <br /> CITY A r,}e C'N CA MP 33(s <br /> ae�.. <br /> COUNTY SRN 3oaFw, M <br /> CONTACT PERSON KI RK o O v m F3 N PHONE NUMBER(20 9 ) <br /> 09M Nmm)- OAK.Mrr►. <br /> DTSC 1772(IM) <br />