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_Awuru" "TirUQUIMULI rrotectiou Agency Department of Toric Substances Control <br /> Check Number Page 1 of <br /> ARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> n P R 0 1 1993 For Use by Hazardous Waste Generators Performing Treatment Elinitial <br /> V Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> ENVIRONMENTAL HEALTH and by Permit By Rule Facilities <br /> C PERMIT/SERVICES <br /> c j 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 each of the four categories and an additional notif cation form for transportable treatment <br /> units (7TU's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. <br /> Number each page of your completed notification package and indicate the total number of pages at the top of each page at the <br /> '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 will not be considered complete without payment of the appropriate fee for each tier under which you are operating. <br /> (Please note that the fee is per 77ER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT S times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this <br /> form. Please write your EPA ID Number on the check. Fill in the check number in the box above. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific not f cation forms you must attach. <br /> Conditionally Eumpt Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (nor per unit) <br /> A. 0 Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 1pt) <br /> B. 2 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. 1 Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. 1 Permit by Rule SC 1772D <br /> ) $1,140 <br /> 9 1:avq�rg <br /> 4 Total Number of Units APS 0 1 1993 Total Fee Attached S 2,380. 0 <br /> H. GENERATOR IDENTIFICATION <br /> ENVIRONMENTAL HEALTH <br /> EPA ID NUMBER CA D 9 8 0 8 9 3 1 8 4 PERMIT/SWMCPJMBER (if available) H AHQ 3 6 L 0 7 8 3 7 <br /> NAME (Company or Facility) Li ka <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 1443 Navy Drive <br /> For DTSC Use Only <br /> CITY Stockton CA ZIP 95206 - <br /> Region <br /> COUNTY San Jo=li n <br /> CONTACT PERSON James, Ne ,l PHONE NUMBER(2n9 )q�,g - ng4g <br /> (Fire Name) (Last Nam-) <br /> DTSC 1772 (1/93) Page 1 <br />