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pepartmea of Toric Substance Cooud <br /> State or California•California Fmrirnat`J Protectiaa A¢� - Page I of 6 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORA/ <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment initial <br /> Under Conditional Exemption and Conditional Authorization, ❑ Renewal <br /> and by Permit By Rule Facilities J@ Amendment <br /> Please refer to the attached Instructions before Completing this form. You may nosh for more than one permitting tier by using this <br /> wification form, D7SC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific norication formsfor each of the four categories and an additional notification form for transportable treatment <br /> units (ITV's). You only have to submit forrns for the tier(j) that cover your unit(s). Discard or recycle the other unwed forms. <br /> Number each page of your completed notification package and indicate the total number of pages at the top of each page nt the <br /> Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested, all folds 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 notification fees 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 Firm THIS N077FICAT70N FORAM. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units-you operate in each tier. This will also be the number of unit speck notification forms you must attach. <br /> Cordirionally Exempt Small Quantity Treatment operations may rot operate units under any other tier <br /> Ntanber of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quantity Treatment D. Z Permit by Rule <br /> B. Conditionally Exempt-Specified Wastestream E. Commercial Laundry <br /> C. Conditionally Authorized F. Variance (Section 25143) <br /> 11. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAP 8 3 Z Q 6 .2 9 BOE NUMBER (if available) Hg Ef_3_ O S 7 y I S <br /> FACILITY NAME6_U 1 r (2 J;jG , �� IZ� — �D✓tr` tTZF <br /> (DBA--Doing Bucims, As) I� / <br /> PHYSICAL LOCATION _f EZD �/1/ <br /> llt <br /> CITY SToc K TZJN / CA ZIPCs20113. <br /> COUNTY `Sprf�j SO f+Q q I N <br /> CONTACT PERSON N LE� ' PHONE NUMBER(= c L E� `tO_� <br /> (Firm Name) (tyt Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME / �TY0,j�pf+l&/0 S� /VJ For DTSC Use Only <br /> WD <br /> ��10 � <br /> STREET l f D t Rem em 1 1-Ee — <br /> Region <br /> CITY K RfT,/ STATE ' <br /> S� ZIP 9sZ�3 <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON L t_Qy_D F f f✓Ley PHONE NUMBERUCt3`f) ! �- tF � <br /> (First Name) (Iia Nome) <br /> DTSC 1772 (1/95) Page 1 <br />