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RECEIVED State of Catiforvis.California F,r evtat Ptim hvteeAQ MAY 2 4 1993 a�> amber MAY HEALTH De coma dTxi, SuWancea Contra+ PERMIT/SERVICES Page I of-3 L v ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION 3 For Use by Hazardous Waste Generators Performing Treamrat 12 Initial Under Conditional Exemption and Conditional.Aut'horiation. ❑ Revised y and by Permit By Rule Facilities Please refer to the attached instmatons before completing this form. you may for more than one not f notion form, DISC 1 TTZ. You must attach a separate unit permitting tier by using this ep specific not fication form for each unit at this location. There are different unit specific notification forms for each of the four categories and an additional notheation form for transportable treatment units (1 ,S). You only have to submit forms for the tiers) 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 folds must be completed except those that state '(f different' or '(f available'. Please type the information provided on this form and any attachments. The not f carton will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that rye fee is per 77ER not per UNIT. For example, if you operate S units btu they are all ConditionaltyAuthorszed, You only owe$1,140, NOT S timer$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you awe$2,2W.) 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 notication forms you must attach. ^.on alutonany Fsernpt Small Quantity 7 reatment Operations may not operate wuu under any other tier. Number of units and attached unit specific notifications Fee per Tier A. Conditionally Exem t-Small (not per udt) Y P Quantity Treatment (Form DTSC 1772A) S 100 B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 C. Conditionally Authorized (Form DTSC 1772C) $1,140 D. permit by Rule (Form DTSC 1772D) $1,140 1 Total Number of Units Total Fee Attached S $ 100 IL GENERATOR IDENTIFICATION EPA ID NUMBER CAS 0 0 0 1 1 1 2 7 9 BOE NUMBER (if available) H_HQ. NAME (Company or Facility) Bear Creek Winery (DBA—Doing Bucineu As) PHYSICAL LOCATION CANANDAIGUA WINE COMPANY 11900 N. Furry Rd. CITYLodi CA ZIP 95240 i For DTSC Um Only _ on OUNTY San Joaquin Reg CONTACT PERSON Ruben Negrete PHONE NUMBER( 209 )368 - 5151#275 (Fico Num) (tam Nam )