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' rCnect humoer _1~+ e:u or AOXNC Nunaxnces l.onuci Page 1 of 23 i "J ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATIOI' 1 FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment ❑ Initial �j Under Conditional Exemption and Conditional Authorization, ❑ Revised ? and by Permit By Rule Facilities e `'?ease refer to the attached Instructions before completing this form. You may not for more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific notification forms for each of the four categories and an additional not f cation form for transportable treatment units (TTU'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 age _ 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. Vie noa fiication will not be considered complete without payment of the appropriate fee for each tier under which you are operating. note that the fee is per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, yoti only owe 51,140, NOT times$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 ID 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. -06onally Exx7npt Small Quantity Treatment operations may not operate units under any other tier. Nurral,ei ,-�f waits and attached unit specific notifications Fee per Tier (nor per unit)A. 0 Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) � 100 B. _2 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 C. 1 Conditionally Authorized (Form DTSC 1772C) $1,140 D. _1 Permit by Rule (Form DTSC 1772D) $1,140 4 Total Number of Units Total Fee Attached S 2,380.00 IIo GENERATOR IDENTIFICATION EPA +:: NUMBER CA D 9 8 0 8 9 3 1 8 4 BOE NUMBER (if available) H AHQ 3 6 0 0 7 8 3 7 NAI IE (Company or Facility) T,i ka (DBA—Doing Business As) PHYSICAL LOCATION 1443 Navy Drive For DTSC Use Only CITY Stockton CA ZIP 95206 - Region COUNTY San Joao n CONTACT PERSON ,TPT7 NPr,1 PHONE NUMBER(2Zo, ) g4p - �cLga (First Nerve) (Last Name) DTSC 1772 (1/93) Page 1