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jute or��Orwa .� ur curuv.....euuu rrvsac A#f ) Page*f,fit heck Number C i D I c> b 5S g 3 0 0 b-6 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION _ For Use by Hazardous Waste Generators Performing Treatment 0 Revised Initial Conditional Exemption and Conditional Authorization, and by Permit By Rule Facilities v Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this notification farm, DISC 1772. You must arrack a separate unit specific notification form for each unit at this location. There are different unit specific noticationforms for each of thefour categories and an additional notiftcationform for transportable treatment units (ITV's). You only have to submit forms for 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 TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, you only owe$1,140, NOT 5 timer$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe$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. 1. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notificationforms you must attach. Conditionally Eranp Small Quantity Deatmatt operations may not operate wits under a ny ' unbax of units and attached unit specific notifications GPe a1'�trC ee per Tier ads NJ, loot per me) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772m O S l00 � Conditionally Exempt-Specified Wastestream (Form DTSC 1772 � 1$93 o. E 100 vli JC. Conditionally Authorized Form DTSC 1772rpt S1,140 D. Permit by RuleForm DTSC 1772it $1.140 LAS Total Number of Units Total Fee Attached f 100.00 II. GENERATOR D)ENTIFICATION U)� cbL:/// �7J (: EPA ID NUMBER CA 2_ _ _ _ BOE NUMBER (if available) H_HQ__ _ __ _ _ _ NAME (Company or Facility) LONGS DRUG STORES rwr TFORNIn TNC (DBA—DoigBuamu Am) LOCATTION PHYSICAL LOCLONGS DRUG STORE #207 1190 North Main Street For DTSC Use Only Cry Manteca CA ZIP Region SAN JOAQUIN OUNTY CONTACT PERSON NANCY SCHNTDBR PHONE NUMBER( sin) 2tn 29 (Fitts Name) (LAs Name) DTSC 1772 (1193) 1 1C 'h Page I