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State of California-California Environmental Protection Agency Department of Toxic Substances Control <br /> Check Number 0 (.I :V 3 3 Page 1 of <br /> 8ti2.�82 r �� 2 ENTERED ti>yY 1. 7 tan <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 /> c� and by Permit By Rule Facilities <br /> tj Please refer to the attached Instructions before completing this form. You may notes for more than one permitting tier by using this <br /> notification form, DTSC 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 notificationform for transportable treatment <br /> units (TTU's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused fonts. <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 S units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT times$1,140. If 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 check. Fill in the check number in the box above. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notiftcationforms 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 noti/ftotls • Fee per Tieri iDfP(r`p/16 A <br /> (not per unit) <br /> A. Conditionally Exempt-Small Quantity-Tieafinent?q CFO DTSC 1772A) $ 100 <br /> B. Conditionally Exempt-Spec4i; 3Vastestream ,y� (oiin TSC 1772B) $ 100 <br /> C. Conditionally Authorized g Q91 (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule 'l ��,��'00 s To DTSC 1772D) $1,140 <br /> ep <br /> _ Total Number of Units Total Fee Attached $ l 0, -- <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAL O v O UBOE NUMBER (if available) H/r H -- D 3 to �i g 6 <br /> NAME (Company or Facility) cl� "c,1 e X 1 C <br /> (DBA—Doing Business As) _ _ II v <br /> PHYSICAL LOCATION 5 5 1 V, j � (T r 1 Via_1 -1 \rh L2r . <br /> ll For DTSC Use Only <br /> CITY r { 1'1 T C C.� — CA zlpq <br /> Region <br /> COUNTY C-k i J O CA,Cj tit0, <br /> CONTACT PERSON1�j �'?��r ��I �� r PHONE NUMBER 2G <br /> (First Name) (Last Name) <br /> tiTcr t 77? (t(41) Page 1 <br />