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vette of C.liforum-CalifoemR �roomm vteccoa Agency Deparlaimt of Toric Substaaces Control CSece Numoer �"' _ Pse I of /�� S6 9 2 0 0 0 1 8 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORNI FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment © initial Under Conditional Exemption and Conditional Authorization, ❑ Revised and by Permit By Rule Facilities :) P!ease refer to the attached Instructions before completing this form. You may notifvfor more than one permitting tier by using this norgication farm. DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. ]here are different unit specific noriftcation forms for each of the four categories and an additional notification form for rransporrable treatment units (TTU's). You only have to submit forms for the tierts) that cover your unit(s). Discard or recycle the other unrated forms. Numoer each page of your completed notification package and indicate the total number of pages at the top of each page at the 'Page — of—'. Pur your EPA /D 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. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that the fee it per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized. You only owe$1,140, NOTS times$1,1I0. If you operate any Permit by Rule units and any units under Conditional Authorization .vou owe 52,280.) 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 LD Number on the check Fill in the check number in the box above. I. NOTIFICATION CATEGORIES ..�....»,. :.:e res.-cer oy units yet operate in encs tier. -,is wiii ase be thenumber of unit specific aaif:caiionjo, a you must attach. Conditionally Exempt Small Quantity Treatment operations may not operate unit/ order any other tier. Number of units and attached unit specific notifications Fee per Tier cwt per unto A. Conditionally Exempt-Small Quantity, iment (Form DTSC 1772A) S 100 4 Silts, B. 2 Conditionally Exempt-Specifi Vt4;i!}�arii vo�O l DTSC 1772B) S 100 m�° C. Conditionally Authorized qp (fo DTSC 1772C) $1,140 D. Permit by Rule ea , Ro-119 93 (fo DTSC 1772D) $1,140 J4=e= /Hen/� CaF, s h Se n 2 Total Number of Units 9�9q tyre' Total Fee Attached S 100.00 fCNTO R. GENERATOR IDENTIFICATION EPA ID NUMBER CA D 0 0 9 1 1 9 3 1 4 BOE NUMBER (if available) H AHQ3 6 0 0 7 8 7 ———— —— — — — — — — — —— 9——— NAME (Company or Facility) SIMPSON PAPER COMPANY DBA—Doing Busman As) PHYSICAL LOCATION 942 SOUTH STOCKTON AVENUE For DTSC Use Only CITY RIPON CA ZIP 95366 2761 Region COUNTY SAN JOAQUIN CONTACT PERSON DENNIS ABRARAMSON PHONE NUMBER(209 ) 599 . 0275 (Fint Nun) (Vd Name) DTSC 1772 (1/93) Page I