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..,.UI �.�YIO(9Y -�.a,u„su� c..r.n,,.s..u.•-- `uuu noes) r .. Check umber Pag%vf y tl ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment ®t Initial Under Conditional Exemption and Conditional Authorization, ❑ Revised v and by Permit By Rule Facilities :j 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 not fication form for each unit at this location. There are different unit specific notification forms far each of the four categories and an additional notif cation form for transportable treatment units (ITV's). You only have to submit forms far 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 TTER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, you only owe$1,140, NOT S tinter$1,140. Ij you operate any Permit by Rule units and any units under Conditional Authorization you awe $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 m Number on the check Fill in the check number in the box above. L NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notif cation forms you must attach. Conditionally F.rnnpt Small Quantity Treannent operations may trot operate units under any other tier umbe of emits and attached unit specific notifications Fee per Tier tnut per muq A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) E 100 B. XXX Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 C. Conditionally Authorized (Form DTSC 1772C) S1.140 D. Permit by Rule (Form DTSC 1772D) $1.140 4r Total Number of Units Total Fee Attached S 100.00 II. GENERATOR IDENTIFICATION EPA ID NUMBER CA LOQU43992—— — — BOE NUMBER (if available) H_HQ_ _ _ __ _ _ _ NAME (Company or Facility) TQNaS DRUG SZ=sr r rnnomrn INN (DBA—Doing Business As) PHYSICAL LOCATION LONGS DRUG STORE #207 1190 North Main Street For DTSC Use Only CRY Manteca CA ZIP 95446 Region SAN JOAQUIN 'OUNTY CONTACT PERSON NANCY SCHNtprg PHONE NUMBER( sin)�)n SF�s (Fin Name) (Lan Name) Page I DTSC 1772 (1193)