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xafe of r.crorsua-�a orma�, o®m raEemm Agency _ <br /> Deparmmr of Toric saLaacas tmto) <br /> Page t C: <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous W&U, Cteaeracors Performing Treatment ❑ Initial <br /> Under Conditional F-xenon alta C xxiitionu Authorizatim. u neaewai <br /> and by Permit By Rule Facilities ❑ Amenammt <br /> Please refer to the attached Inrrri axons before completing this form. You may norifyjor more than one permitting tier by uswg mu <br /> norifirntion jorm. DISC I TT1. You must attach a separate unit specific not noation form for earih unit at this loratiots. There are <br /> different unit specific notification forme for each of the jour categories and an additional mrifrtarion form for transportable irearmmc <br /> units (177J'S)- You only have to submit forms for the tier(s) that corer your unitis). Discord or recycle the other unused forme <br /> Number each page of your completed notification package and indicate the total number of pages at the top of each page ah the <br /> 'Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested: all fields muu be <br /> completed excepr those that state 'if different' or 'if available'. Please type the information provided on this jotm and aor <br /> anachmenrs. <br /> The notification fees are assessed on the basis of the number of tiers the notifier will operate ht»da•, and will be calleaed by the Stare <br /> Board of Egruuization. DO NOT SIM OUR FEE ATIA 77970 E-OMCA77ON FORM, <br /> L NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will aLro be the number of unit spenfhe nor,,'ficarion forms Wit must ahrata <br /> �i°^°BY Fsanpt Small Qh away rrram ew opermionr may nor operate units wider ny er aother riM <br /> Ntnnber of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quanuty Treatment D. Permit by Rule <br /> B. XX Conditionaily Exempt-Specified Wastestresm E- Commercial Laundry <br /> C. Conditionally Authorized F. Variance (Satioa 25M-7) <br /> U. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CALLOQ0_L7LUQ._____ BOE NUMBER (if available) H_HtZY_OHC 30-66694346 <br /> FACIIITYNAME Wal-Mart Store#p1554 One Four Fhoto <br /> (DRA—Doing m) <br /> PHYSICAL LOCATION 370:? east Hammer Road <br /> CITY Stockton CA ZIP 952' 2 <br /> COUNTY San Jnarijin <br /> CONTACT PERSON Shelia McDonald PHONE NUMBER( 209) 473 - a 8 5 4 <br /> (Feat Name) (La Namel <br /> MAILING ADDRESS, IFPIFFERENT: <br /> COMPANY NAME Same as ah„ve <br /> Fat:VTSC: <br /> ear duly <br /> STREET <br /> CITY STATE ZIP 44 <br /> COUNTRY <br /> 40V)r<omptete,caa usA) <br /> CONTACT PERSON PHONE NUMBER() - <br /> (Fav Name) (Lett Name) <br /> DISC 1772 (1/95) Page i <br />