Laserfiche WebLink
Sar of Cai/erm • CaHerm Faviremmial r me A4awz Ogarsw of Tera Saboutwo Caaat <br /> Pale I of I <br /> 92 00047 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators PerforminS Treatment x <br /> Initial <br /> Under Conditional Exemption and Conditional Autbonzation. ❑ Revised <br /> and by Peraut By Rule Facilities <br /> C <br /> 4 <br /> H Please rejtr to the attached Instructions before completing this form. Yom may ratify for more than one permitting tier by using this <br /> notification form, DTSC 1777. You must attach a separate unit specific norificarion fors for each unit at this location, There are <br /> different unit specific notification fare for each of rhe four categories.and am additional norification form for transportable treatment <br /> units (ITU's). You only have to submit forms for rhe rier(J) that cow your un(t(s)• Discard or recycle the other unused forms. <br /> Number each page of your completed notification package and Indican rhe 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. aU ffeUi must be <br /> completed except those that state 'ij different' or 'if available'. Please type the lnjormarion provided on dtis form and any <br /> .U,r, h sews. <br /> The notification will not be considered complete without payment of the appropnme jec jo►each tier under which you are operating. <br /> (Please rare that the fee u per TIER not per UMI: For example, ff you Operate 3 unity bre they are all Condhfonally Audionzed, <br /> lou only owe$1,110, NOT S Mmes$1,110. If you operate any Penns by Rule win and any will under Condidonal Authorization <br /> you owe$2,230.) Checks should be made payable to the Deparrmem of Tawe Subsittown Conal and be stapled to the top of this <br /> john. Powe write your EPA M Number on the cheat Fill In the deck number In the bats above. <br /> L NOTIFICATION CATEGORIES <br /> Indicate the number of umis you operate in each tier. This mU alto be the number of wit sPrCYIe nmifi=wn forms you mmn anach. <br /> Cor dawmaUy Exempt .Sawa!/Quantity T1a®mtnr apesar(aar Racy not opsyme wits mmdw ay odaw tie. <br /> Number of units and attached unit spadfk ootincations Fee pe Tic <br /> Ar per� <br /> A. Coodivaaally Exempt-Small Quanuty Treatment (Form DTSC 1772A) f 100 <br /> H. 4 Conditionally Exempt-Specified Waptaam:: >; orm DTSC 17728) $ 100 <br /> . A <br /> C. rooditionally Authorized �= DTSC 17720 $1.140 <br /> D. Permit by Rub MAR3119 (Fam DTSC 1772D) $1.140 <br /> ---- 993' --------- <br /> Cw iee:fi's�'^re'nc,e <br /> 4 Total Number of Unita />® Total Fee Anrhad $ /00 r- <br /> EL GENERATOR IDENTIFICATION <br /> xpc f2 D�� <br /> EPA ID NUMBER CA ————— BOE NUMBER (if avail") H—HQ.—_—— <br /> NAME (Company or Facility) <br /> M"-00M <br /> Y 11kiiiiiiiiss As) <br /> SICCAAL LOCATION Z 0s, <br /> fV r t; t1 C E ePt <br /> 0 , i�OX 1 �I <br /> _ Fes DTSC Ur Only <br /> CITY CA 23P <br /> COUNTY R <br /> CONTACT PERSON PHONE NUMBER(2 ti) jL - 31 1 <br /> arms Neeal (La tear! <br /> DTSC 1772(1/93) iii. _ f: <br />