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SIa4 0(Cnliforniy-Califorria Fn�iroomental Protection Agency fl✓r Deparmreot of Toric Substances Canted <br /> RONMEHTA Page I of 8 <br /> j 1W L HEAL T! <br /> ONSITE HAZARDOUS WASTE TVA r�T`W&ffiCATION FORM <br /> FACILITY SPEC IC' CON <br /> For Use by Hazardous Waste Generators Performing tmeat ® Initial <br /> Under Conditional Exemption and Conditional Authorization, ❑ Reaewal <br /> and by Permit By Rule Facilities ❑ 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 notificarion form for each unit at this location. There are <br /> different unit specific notification formsfor each of thefour categories and an additional notification form for transportable treatmem <br /> units (7771s). You only have to submit forms for the der(s) that cover your unu(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 m 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 notificationfees 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 VeTM 7795 N071FIC.177ON FORM <br /> I. 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 Exempt Small Quantity Treatment operations may not operate unix under any other tier. <br /> Number of units 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 Wastestrmin E. 0 Commercial Laundry <br /> C. Conditionally Authorized F. 0 Variance(Section 25143) <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA D 0 0 9 1 1 5 2 3 9 BOE NUMBER (if available) HFHQL 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 Hydrite Chemical Co. <br /> (DBA—Doing Busimsa N) <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 /> (Fort Name) (Ln Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME US Chemical For DISC Use ody <br /> STREET 300 N. Patrick Blvd. Region <br /> CITY Brookfield STATE WI ZIP 53045 . 0948 <br /> COUNTRY <br /> (oily complete if not USA) <br /> CONTACT PERSON Tracy Toltzman PHONE NUMBER(414 ) 792 - 1450 <br /> (Ent Na=) (Ga Nam) <br /> DTSC 1772 (1/95) Page I <br />