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r t.aWeaYa ryrwuwmuu rfLK Wa M1'._'1 ✓c Y+'-.•••a.. ... .....� .wvv.uao ..,� .. <br /> State of C4li.orwa• Page 1 of 6 <br /> haat N••mMi _1 �.'�> >. _ <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment ® Initial <br /> under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> j Please refer to the attached instructions before completing this form. You may notify for more than one permitting tier by using this <br /> notification form, D7SC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for each of the four categories and an additional notification form for transportable treatment <br /> units (ITU's). You oniv have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. <br /> Number each page of your completed notification package and indicate the 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; all fields must be <br /> completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any <br /> attachments. <br /> The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. <br /> (Please note that the fee is per TIER not per UNIT: For example, if you operate 5 units but they are aU Conditionally Authorized, <br /> you only owe$1,140, NOT 5 times$1,140. 1f you operate any Permit by Rule units and any units under Conditional Authorization <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 /> form. Please write your EPA ID Number on the cheat Fill in the check number in the box above. <br /> L NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific roti arionforms you mutt attach. <br /> Conditionally Exempt Smaa Quantity Treannent operations may mat operate uaitr under any <br /> oosyb -Co <br /> Number of units and attached unit specific notifications 4u asta a'1�ioo Fee per Tic <br /> ro Cm vo a t /rot per runt) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 17 S, $ 100 <br /> B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 1 B) APR O 1 1993 $ 100 <br /> California Department <br /> C. Conditionally Authorized (Form DTSC 1772 of Health Services $1,140 <br /> 04 CRF.M`it1SO <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> Total Number of Units Total Fee Attached $ 100 <br /> 11. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAD 0 0 0 6 2 6 1 0 1 BOE NUMBER (if available) HLHQ _L .L LL 7 7 6 <br /> NAME (Company or Facility) Time Oil Co. <br /> (DBA—Doing Bustmes As) <br /> PHYSICAL LOCATION 3015 Navy Drive <br /> For Iyl'SC Uae Orly <br /> CITY Stockton CA ZIP 95206-1991 <br /> Region <br /> COUNTY San Joaquin <br /> CONTACT PERSON Charlie Kyle PHONE NUMBER 2( O9 ) 462 - 3848 <br /> (First Name) (last Name) <br /> r)Tc(- 1771 (1/93) Pace I <br />