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State of California - California Faviroomental Protection AgeocY Department of Toxic Substaoem Cootrd <br />'^ Check Number <br />GT %h)y Page 1 of 15 <br />I 9 2 0 V�0 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 />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, DISC 1772. You must attach a separate unit specific notifcation form for each unit at this location. There are <br />different unit specific nottf cation forms for each of the four categories and an additional nonf cation form for transportable treatment <br />units (77U's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forma. <br />Number each page of your completed nonf 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 any <br />attachments. <br />y <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 all Conditionally Authorized, <br />you only owe $1,140, NOT 5 times $1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br />you owe $2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this <br />form. Please write your EPA ID Number on the check Fill in the check number in the box above. <br />[. NOTIFICATION CATEGORIES <br />Indicate the number of units you operate in each tier. This will also be the number of unit specific nonf cation forms you must attach. <br />Conditionally Erertpt small Quantity Treatment operations may not operate units under any other tier. <br />Number of units and attached unit specific notifications Fee per Tier <br />pat per amu) <br />A. Conditionally Exempt -Small Quantity Treatment (Form DTSC 1772A) S 100 <br />B. 4 Conditionally Exempt -Specified Wastestr <br />C. Conditionally Authorized <br />D. Permit by Rule F <br />PJ�AR 2 91993 <br />4 Total Number of Units o oanme^t <br />IV I Co <br />IL GENERATOR IDENTIFICATION s�,�RAM�EN�So <br />EPA ID NUMBER CAD 0 0 5 4 1 5 6 33— <br />NAME (Company or Facility) <br />(DBA–Doing Business As) <br />PHYSICAL LOCATION <br />CITY <br />COUNTY <br />CONTACT PERSON <br />(Form DTSC 1772B) <br />DTSC 1772C) <br />DTSC 1772D) <br />$ 100 <br />$1,140 <br />$1,140 <br />Total Fee Attached $10 0 . 0 0 <br />BOE NUMBER (if available) H�_ HQ 3 _6 0 0 9 0 1 1 <br />Libbev-Owens-Ford Co. <br />500 E. Louise Ave. <br />Lathrop <br />San Joaquin <br />CA ZIP 95330 <br />For DTSC Use Only <br />Region <br />Jon Pleiss PHONE NUMBER(' 09) 35C76202 <br />(lea Nsme) <br />�Fim Name) <br />DTSC 1772 (1/93) Page I <br />