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gilt of(.aWorwa - A4;n ) ✓cy�.'....o.. ,,. .,,u .y..nu.ae ", <br /> Clwct N.-mber Page 1 of 6 <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 /> i <br /> j Please refer to the attached Instructions before completing this jonm. You may notify jar more than one permitting tier by using this <br /> notification form, DISC 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 jour categories and an additional notification form for transportable treatment <br /> units (711's). You only have to submit forms for the rier(s) that cover your unit(s). Discard or recycle the other unused fomes. <br /> Number each page of your completed not f cation package and indicate the total number of pages at the top of each page at the <br /> 'Page _ of— <br /> pt those that state 'if different' or 'if available'. Please type the information provided on this form and am <br /> attachments. <br /> The notfcation will not be considered complete without payment of the appropriate jet for each tier under which you are operating. <br /> (Please note that the fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT 5 time$1,110. 1f you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe 52,280.) 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 m Number on the check. Fill in the check number in the bax 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 notification forms you must attach. <br /> Conditionally Exempt Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific ratifications Fee per Tia <br /> (not per wit) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 17728) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) 21.140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> Total Number of Units Total Fee Attached S 100 <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAD 0 0 0 6 2 6 1 0 1 BOE NUMBER (if available) HLHQ_3 6 L LL 7 7 6 <br /> NAME (Company or Facility) Time Oil Co. <br /> (DEA—Doing Buaincu As) <br /> PHYSICAL LOCATION 3015 Navy Drive <br /> For DISC UK Only <br /> CITY Stockton CA ZIP 95206-1.191 <br /> Region <br /> COUNTY San Joaquin <br /> CONTACT PERSON Charlie Kyle PHONE NUMBER 2( 09 ) 462 - 3848 <br /> (Fina Name) (1Jr Name) <br /> r)TSC 1772 (1(03) Pave I <br />