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State or California-California FAviromnet�4oteMion Agency J Department of Toxic Substances Control <br /> Page 1 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 Penhit 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, DTSC 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 /> (TTU's). You only have to submit forms for the tiers)1category(fes) 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 /> I. 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 of 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 /> IL GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAJQ j!1 !2_ +11 j 3 ( BOE NUMBER (if available) HA_HQ3 ('o a o 1'2 T(Z <br /> FACILITY NAME Fc X [Z e Je-r �t a tit— Ca <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 6 H Z S A�c L A-o n Ave . <br /> CITY R , e^ CA ZIP '15_3(.4 <br /> COUNTY <br /> CONTACT PERSON e--V\r\CS (A breAvns� PHONE NUMBER(_?-�)_5�- !� .t7r <br /> (First Name) past Name) <br /> MAMING 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 1 <br />