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Sur*of C.Jifornia-CA norma FnrUoam—' � -•ion Agency Dtpar=eas of,one �ubazaees Canted <br /> V <br /> Page 1 of <br /> TE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment Initial <br /> `w ,��`uJ -��' ^ Under Conditional Exemption and Conditional Authorization, .� R i <br />-,j1, ��`� 1 1and by Permit By Rule Facilities \ <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, DISC 1777. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for each of the four categories and an additional notification form for transportable treatment <br /> units (77Z1's). You only have to submit forms for the tiers) 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 FPA ID 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 /> attachments. <br /> The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. <br /> (Please note that the fee is per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> you only owe 51,140, NOT times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe 52,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this <br /> form. Please write your EPA ID Number on the check- Fill in the check number in the box above. <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 artarh- <br /> Condirionally Exempt Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (not per unit) <br /> A. 0 Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 <br /> B. _-f-S Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. 1 Conditionally Authorized (Form DTSC 17720) $1,140 <br /> D. _0 Permit by Rule (Form DTSC 17720) $1,140 <br /> (o Total Number of Units Total Fee Attached S 1 y2ao <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAD 0 0 9 1 8 9 0 6 9 BOE NUMBER (if available) H_LIIQL 6 0 Q 6 6 _ 7 <br /> NAME (Cotmpaay or Facility) -BLE <br /> (DBA-Doing Busiacsa As) <br /> PHYSICAL LOCATION 3,197 S. A i r�r+ Wan <br /> For DTSC Usc On)y <br /> CITY Stockton CAZIP 4�-�_ <br /> Rcgion <br /> -j-- <br /> COUNTY San Joaquin <br /> G e.rr led 321(o <br /> CONTACT PERSON -1 ent *itaaewa PHONE NUMBER) 98I <br /> (Tint Naam) (test Nanw) <br /> DTSC 1772 (1/93) Page I <br />