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State of California-California Environmental Protection Agency Department or Toxic Substances Control <br /> Page I of <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION ❑ Initial <br /> For Use by Hazardous Waste Generators Performing Treatment ❑ Amended <br /> Under Conditional Exemption and Conditional Authorization, <br /> and by Permit By Rule Facilities <br /> Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> notification form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for five of the categories and an additional notification form for transportable treatment units <br /> (ITU's). You only have to submit forms for the tier(s)lcategory(ies) that cover your unit(s). Discard or recycle the other unused <br /> forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at <br /> the 'Page_ of_'. Put your EPA ID Number on each page. Please provide all of the information requested; all fields must be <br /> completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any <br /> attachments. <br /> The notification fees are assessed on the basis of the highest tier the notifier will operate under and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE PAYMENT WITH THIS NOTIFICATION FORM. <br /> 1. 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 <br /> must attach. Conditionally Exempt Small Quantity Treatment operators may not operate units under any other tier. <br /> Number or units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quantity Treatment (CESQT) D. Permit by Rule(PBR) <br /> B. Conditionally Exempt-Specified Wastestream (CESW) E. _ CE--Commercial Laundry (CE-CL) <br /> C. Conditionally Authorized (CA) F. Conditionally Exempt-Limited (CEL) <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAD 1 g 2 O O 4 Q�'' ff� 1 BOE NUMBER (if available) H_HQ____ <br /> FACILITY NAME �DS U.rii�11�e COf`Qt)ftAUOY� <br /> (DBA--Doing Business As) -t <br /> PHYSICAL LOCATION Iv1D�bl Wlellov� kie, <br /> CITY CA ZIP RSC337. ll <br /> COUNTY Saw J oOu u i K <br /> CONTACT PERSON 1)0.Vi8 PHONENUMBER(209 )M9 -V.3gg <br /> (First Name) (Iasi Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME . <br /> STREET <br /> CITY STATE ZIP - <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON PHONE NUMBER(_) - <br /> (First Name) (Last Name) <br /> DTSC 1772 (1/96) Page I <br />