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Sate of Califomio - California Fnvirri m®rat Protection Agency ,ser mt of Tone Srbdiusees Control j Page G,,; Chect Number u' a ,,;y a i ge— ` MFR 2 q 1:71-1,14 ONSITE HAZARDOUS WASTE TRE1 F.NT N0TIF'16ATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment ® Initial Under Conditional Exemption and Conditional Authorization, ❑ Revised and by Permit By Rule Facilities Please refer to the attached Instructions before completing this farm. You may notify for more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specific notifcation form for each unit at this location. There are different unit specific notif cation forms for each of the four categories and an additional notif cation form for transportable treatment units (=s). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at the 'Page _ of _'. Put your EPA ID Number on each page. Please provide all of the information requested; all fields must be completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any attachments. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that the fee is per TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, you only owe $1,130, NOT 5 timers $1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe $2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA ID Number on the check Fill in the check number in the box above. L NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. 77iis will also be the number of unit specific not f cation forms you must attach. Conditionally Eronpt Small Quantity Treatment operations may not operate unas wrier any other tier. Number of units and attached unit specific notifications Fee per Tier (nor per unit) A. Conditionally Exempt -Small Quantity Treatment (Form DTSC 1772A) S loo B. 4 Conditionally Exempt -Specified Wastestream C Conditionally Authorized D. Permit by Rule 4 Total Number of Units 0. GENERATOR IDENTIFICATION EPA ID NUMBER CAD 0 0 5 4 1 5 6 33 NAME (Company or Facility) (DBA—Doing Burineu Aa) PHYSICAL LOCATION CITY COUNTY CONTACT PERSON DTSC 1772 (1/93) (Form DTSC 1772B) (Form DTSC 1772C) (Form DTSC 1772D) $ 100 $1,140 $1,140 Total Fee Attached $100 . 00 BOE NUMBER (if available) LiObev-Owens-Ford Co. 500 E. Louise Ave. Lathrop San Joaquin CA ZIP 95330 - For DTSC Uu Only Region Jon Vleiss PHONE NUMBER 209) 35076202 (First Name) (LAu Name) Page I