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Jane of CAUorIDa-C&hfornia Faris®®at .iMacnoo Aamcy Deparmmt of Toric G.Mawas Caoud <br /> Page i of <br /> ONSITE HAZA19DQUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Geaeruors Performing Treatment ❑ Initial <br /> Jtrtler Coaditiooal Exemption and Corttliaooai Authorization. _ u R©_ww <br /> and by Permit By Rule Facilities ❑ 4.mmnmeru <br /> Please refer to the arradied Instructions before completing thisform. You may notify for more than one permuting tier by using this <br /> nott)icatton form, DISC 7777. 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 mregones and an additional nottftcation form for transportable trearmera <br /> unus (='s). You only have to submit forms for the tiers) that cover your unitts). Discard or recycle the other unread form. <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 EPA ID Number on each page. Please provide all of the information requested; all fieldr must be <br /> completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any <br /> atracimments. <br /> The notification fees are assessed on the basis of the number of tiers rhe notifier will operate under, and will be collected by the Stam <br /> Board of Equalvtuion. DO NOT SKID YOUR FEE W M 77175 NO7_WC4770N 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 muss aro ch <br /> Conditionally Exist" Small Quantity Trrattou operations may rot opeime tmtts ruder any other sic. <br /> Number of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Stall Quantity Treatment D. Permit by Rule <br /> B. _ Cooditionally Exempt-Specified Wwmtream E. Commercial Laundry <br /> C. Conditionally Authorized F. Variance (Section 23205.7) <br /> 11. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAL000126635 ____ BOE NUMBER (if available) H_HQ SY OHC30 694346 <br /> FACILITY NAME -Wal-Mart One Hour Photo #:2025 <br /> (DEA—Dour Boaineaa Aa) <br /> PHYSICAL LOCATION join West Grant Line Road <br /> CITY Trary CA Zip 05376 - <br /> COUNTY San Joaquin <br /> CONTACT PERSON Lorena Martinez PHONE NUMBER(209 ) 836 - 9362 <br /> (Fut Nana) (tat Namc) <br /> MAILING ADDRESS, j,F'_P_IFFERENT: <br /> COMPANY NAME <br /> LF:wrDTSC Use onlySTREET <br /> CITY STATE _ ZIP <br /> COUNTRY <br /> {on)y<oapWa if as USA) <br /> c,ONTACI' PERSON PHONE NUMBER(---) <br /> (Fut Name) (Lt Name) <br /> DTSC 1772 (1/95) Page 1 <br />