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State of California - California E,nrir a( Protection A;mcy <br />Depa mteot of T03de Sahsbma Cootxal <br />Page 1 of <br />ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br />FACILITY SPECIFIC NOTIFICATION %z i25' <br />For Use by Hazardous Waste Generators Performing Treatment ������/// <br />Under Conditional Exemption and Conditional Authorization, ❑ Renewal <br />and by Permit By Rule Facilities ❑ Amendment <br />Please refer to the attached Instructions before completing this form. You may notes for more than one permitting tier by using this <br />notification form, DISC 1777. You mart attach a separate unit specific notification form for each unit at this location- There are <br />different unit specific notification forms for each of thefour categories and an additional noticadon form for transportable treatment <br />units MM's). You only have to submit forms for the der(s) that cower your unit(s). Discard or recycle the other unused fomas. <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 _'. Pur your EPA M Number on each page. Please provide all of the information requested; all fields must be <br />completed except those that stare 'if different' or 'if available'. Please We the information provided on this form and any <br />artachments <br />The notification fees are assessed on the basis of the number of tiers the notifier will operate undo-, and will be collected by the su}te <br />Board of Equalization. DO NOT SEND YOUR FEE WTTH TRIS N077FICA770N 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 ExenPt Small Quantfty Treatment operations may not operate units under any other tier. <br />Number of units and attached unit specific notifications for each tier reported. <br />A. L_ Conditionally Exempt -Small Quantity Treatment <br />B. Conditionally Exempt -Specified Wastestream <br />C. Conditionally Authorized <br />II. GENERATOR ME1NTIFICATION <br />EPA ID NUMBER CAL) Q (a $ 6 <br />FACILITY NAME <br />(DBA—Doing Busmen As) <br />PHYSICAL LOCATION <br />CITY . • ' <br />COUNTY) <br />D.Permit by Rifle <br />E. '�{ �otnmercial Lanadty 4 <br />`=' <br />F._"��V ee (Section 143) <br />1995 <br />r' <br />BOE NUMBER (if available} H",nvQ <br />CA ZIP �26 (n - <br />CONTACT PERSON aiPHONE NUMBER O?)7 <br />(Fira Name) V (Last Name) <br />MAILING ADDRESS, IF DIFFERENT: <br />COMPANY NAME <br />STREET <br />CITY <br />STATE ZIP <br />For DTSC Un Only <br />Regio. <br />COUNTRY <br />(only complete if not USA) <br />CONTACT PERSON PHONE NUMBER(_) - <br />(Frst Name) (Last Name) <br />DTSC 1772 (1/95) Page 1 <br />