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State of California-Ulilt rada Esrirouwental hWactisn Ageaa:1' , . DaWrtmmt of Toxic Substances Control 79W9—J_ " � I Page 1 of 15 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION cYi For Use by Hazardous Waste Generators Performing Treatment JK Initial Under Conditional Exemption and Conditional Authorization, ❑ Revised ,01 and by Permit By Rule Facilities r$ Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specific notfcation form for each unit at this location. There are different unit specific notification form for each of thefour categories and an additional notiftcationform for transportable treatment units (TTU's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at the Page _ of _'. Put your EPA ID Number on each page. Please provide all of the information requested; all fields must be completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any attachments. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that the fee is per ITER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, you only owe$1,140, NOT S times$1,140. ff you operate any Permit by Rule units and any units under Conditional Authorization you owe$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA ID Number on the check. Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific not fcation forms you must attach. Conditionally Exempt Small Quantity Treatment operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier (not per unit) A. 0 Conditionally ExemptSmaB Quantity Treatment (Form DTSC 1772A) $ 100 B. 0 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 C. 0 Conditionally Authorized (Force DTSC 1772C) $1,140 D. 2 Permit by Rule (Form DTSC 1772D) $1,140 2 Total Number of Units Total Fee Attached $ 1 , 14 0 H. GENERATOR IDENTIFICATION EPA ID NUMBER CAD 9 8 2 3 7 0 6 2 9 BOE NUMBER (if available) HA HQ 3 6 0 3 3 1 3 3 NAME (Company or Facility) Citation Enterprises , Inc . (DBA—Doing Businaa As) PHYSICAL LOCATION IS48 W. Field Avenue For DTSC Uw Only CITY Stockton CA ZIP 95203 lRepon- COUNTY San Joaquin CONTACT PERSON peaav Fleck PHONE NUMBER 2( 09 ) 466_ 3607 (Fina Name) (IAa Name) DTSC 1772 (1/93) Page 1