Laserfiche WebLink
State of California-California Eurirwnientat Protection Agency `-� }!.geyattmua[4f.Tutpe s ttnces Control <br /> tFETB1519% <br /> le 1 f 8 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOAION FORMFACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing T IntUnder Conditional Exemption and Conditional Author ❑ R wal <br /> and by Permit By Rule Facilitiess'9CgAMVN C1 Amendment <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, D7SC 1772. You must attach a separate unit specific not fication form for each unit at this location. ])here are <br /> different unit specific notification forms for each of the four categories and an additional rwtifncation form for transportable treatment <br /> units (77U's). You only have to submit forms for the tier(j) that cover your unit(s). Discard or recycle the other unused forms. <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 not fication fees are assessed on the basis of the number of tiers the notifier will operate under, and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE WrM THIS N077F1C477ON FORM. <br /> L 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 Fre mpt Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of hunts and attached unit specific notifications for each tier reported. <br /> A. 0 Conditionally Exempt-Small Quantity Treatment D. 0 Permit by Rule <br /> B. 0 Conditionally Exempt-Specified Wastestrmm E. 0 Commercial Laundry <br /> C. 1 Conditionally Authorized F. 0 Variance(Section 25143) <br /> H. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAD 0 0 9 1 1 5 2 3 9 BOE NUMBER (if available) H F HQ3 8 0 0 1 _5_4_2 <br /> H Y H Q 3 6 0 3 3 5 6 1 <br /> FACILITY NAME US Chemical a Division of HVdrite Chemical Co. <br /> (DBA—Doing Boaineu As) <br /> PHYSICAL LOCATION 1 448 Shaw Road <br /> CITY Stockton CA ZIP 95215 <br /> COUNTY San Joaquin <br /> CONTACT PERSON Joe Ryan PHONE NUMBER(209)948 -3035 <br /> (Finn Name) (La Name) <br /> MAELING ADDRESS, IF DIFFERENT: <br /> l ica <br /> COMPANY NAME US ChemFor DTSC Use Only <br /> S'T'REET 300 N. Patrick Blvd. Region <br /> Com. Brookfield STATE WI ZIP 53045 - 0948 <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON Tracy Tol zman PHONE NUMBER(414 ).792 - 1450 <br /> (First Name) (Lau Name) <br /> DTSC 1772 (1/95) Page I <br />