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hate of California-California Fnvironmeol Protection Agency Department of Toric Substances Comma Page 1 of 9 Check Number - �/ fin/ 9 2 O O O p 9 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION v For Use by Hazardous Waste Generators Performing Treatment ® Initial U Under Conditional Exemption and Conditional Authorization, Revised y and by Permit By Rule Facilities to Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this notification form, DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific notification forms for each of the four categories and an additional notifrcationform for transportable treatment units (77U's). You only have to submit forms for the tiers) 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$1,140, NOT 5 times$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. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notif cation farms you must attach. Conditionally Exempt Small Quantity Treatment operations may not operate unit under any other her Number of units and attached unit specific notifications Fee per Tier (nor per unit) A. Conditionally Exempt-Small Qdagj�fyGeta� t (Form DTSC 1772A) $ 100 B. Conditionally Exempt-Sp6at' ,pd WastestreanfF (Form DTSC 1772B) $ 100 C. Conditionally Authori*d y ' ( orm DTSC 1772C) $1,140 Iq y 5 1993 orm DTSC 1772D) $1,140 D. 1 Permit by Rule --_= Nheallhs�a nmom Nkes S 1 Total Number of Units �ORAMENSO Total Fee Attached $ 1,140 II. GENERATOR IDENTIFICATION EPA ID NUMBER CAD 0 9 Z Q Si -.a 12 _6 BOE NUMBER (if available) H A HQ 6 0 1 7_5 9 8 NAME (Company or Facility) SUMIDEN WIRE PRODUCTS CORPORATION (DBA—Doing Business As) PHYSICAL LOCATION 1412 EL P I N A L DRIVE For DTSC Use Only CITY STOCKTON CA ZIP 95205 _ Region COUNTY SAN JOAQUIN CONTACT PERSON WAYNE MANNOR PHONE NUMBER( 209) 466 8924 (First Name) (Law Name) DTSC 1772 (1/93) Page 1