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trV <br /> Sate of California-CaLifornia Fnvir mad Protection Agency Department of Toxic Substances Coo <br /> Page I of <br /> . � <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> „�, FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment ❑ Initial <br /> °10 Revised <br /> APR 0 2 Under Conditional Exemption and Conditional Authorization, <br /> N\ uIL''IIHE�.A@L; ;.t and by Permit By Rule Facilities <br /> c �Nr UtFaY�l't='frYskKJ�ti <br /> riy Please refer ons 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 notificationform for each unit at this location. There are <br /> different unit specific notif cation forms for each of the four categories and an additional notif cationform for transportable treatment <br /> units (777J'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 feldr 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 TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT 5 timer$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. 7his will also be the number of unit specific notificationforms you must attach. <br /> Conditionally Exempt Small Quantity DYeaiment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (not per wit) <br /> A. _\! Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. X Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> 1 <br /> Total Number of Units Total Fee Attached $ <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CALL a 20Ig�91 c�BOE NUMBER (if available) <br /> / <br /> NAME (Company or Facility) C , l e f.l M r1 ,7 (o Yl <br /> (DBA—Doing Businew As) <br /> PHYSICAL LOCATION 5 y((p e <br /> For DTSC Use Only <br /> CITY �Y� CA ZIP <br /> � Region <br /> COUNTY )) f�T� <br /> CONTACT PERSON ! ( PHONE NUMBER�r —I t.t_iCJ <br /> (First Name) Name) <br /> DTSC 1772 (1/93) Page 1 <br />