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State of California-California Environmental Protection Agencv Department of Toxic Substances Control <br /> Page 1 of 6 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION Initial <br /> For Use by Hazardous Waste Generators Performing Treatment ❑ Amended <br /> Under Conditional Exemption and Conditionai Authorization, <br /> and by Permit By Rule Facilities <br /> Please refer to the attached Instructions before completing this form. You may notifi>for more than one permitting tier by using this <br /> notification-form, DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for five of the categories and an additional notification form for transportable treatment units <br /> (TTU's). You only have to submit forms for the tier(s)/categorv(ies) that cover your unit(s). Discard or recycle the other unused <br /> forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at <br /> the 'Page_ of_'. Put your EPA ID Number on each page. Please provide all of the information requested, all fields must be <br /> completed ercept those that state 'if different' or 'if available'. Please type the information provided on this form and any <br /> attachments. <br /> The notification fees are assessed on the basis of the highest tier the notifier will operate under and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE PAYMENT WITH THIS NOTIFICATION 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 <br /> must attach. Conditionally Exempt Small Quantity Treatment operators may not operate units under any other tier. <br /> Number of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quantity Treatment (CESQT) D. Permit by Rule(PBR) <br /> B. L Conditionally Exempt-Specified Wastestream (CESW) E. CE—Commercial Laundry (CE-CL) <br /> C. Conditionally Authorized (CA) F. Conditionally Exempt-Limited(CEL) <br /> U. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAI Q0Qj2a7M_____ BOE NUMBER (if available) H_HQ________ <br /> FACILITY NAME Nebemtcam sl q*nev fl+— <br /> (DBA--Doing Business As) <br /> PHYSICAL LOCATION 4950 Pacific Avenue <br /> CITY Stockton CA ZIP 95207 - <br /> COUNTY San Joaquin <br /> CONTACT PERSON lex Balmr mc PHONE NUMBER( 916) 852 - 7962 <br /> (First Name) (Last Name) <br /> MAELING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME LensCrafters <br /> STREET _ B650 Covernor's Hill Drive <br /> CITY Ci nei nnati STATE OH ZIP 45242 - <br /> COUNTRY <br /> 5242 -COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON Rob Robison PHONE NUMBER( 513 ) 583 - 6274 <br /> (First Name) (Last Name) <br /> DISC 1772 (1/96) Page 1 <br />