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vale of C.Woruu-Caafornia En— nil P*nW+wu Agm, any.g��.sr�� f To+ue juhpYea Cooed aece Numoer . 1?T?9 n. ) _4e 1 of /� APR 01 57,13 ONSITE HAZARDOUS WASTE TREATM$AffRW,TNICAMMFORM FACILITY SPECIFIC NOTIFICAT M11/5ERVIGES For Use by Hazardous Waste Generators Performing Treatment ® Initial Under Conditional Exemption and Conditional Authorization. ❑ Revised and by Pertrut By Rule Facilities n Please refer to the attached Instructions before completing this form. You may notify far more than one permitting tier by icing this norgicatian form, DISC 1772. You must arrach a separate unit specific notification farm for each unit at this location. There are different unit specific notification forms for each of rhe four categories and an additional nonfication form for transportable treatment units (77V's). You only have to submit forms for the tier(s) that cover your unitls). Discard or recycle the other unused forts. .Vumber each page of your completed notification package and indicate the total number of pages at the top of each page at the 'Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested, all fields must be comoieted except those that state 'if different' or 'if available'. Please type the information provided on this form and any attachments. The notification will nor be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that the fee is per TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, .you only owe S1,1 J0, NOT 5 tines$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization toe 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 ID Number on the check. Fill in the check number in the box above. L NOTIFICATION CATEGORIES ...........the number of units you operate in each tier. :.ais n•iii aso be tiie n;urtner of unitSpecific n.:tiIicarian.oris you must attach. Conditionally Eumpt Small QuamV Dia mast operations may rot opataw unit:under any other tier. Number of units and attached unit specific notifications Fee per Tier wt per w o A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 B. 2 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) S 100 C. Conditionally Authorized (Form DTSC 1772C) S1,140 D. Permit by Rule (Form DTSC 1772D) S1,140 2 Total Number of Units Total Fee Attached S 100.00 11. GENERATOR IDENTIFICATION EPA ID NUMBER CA D 0 0 9 1 1 9 3 1 4 BOE NUMBER (if available) H AHQ3 L 0 11 L8 7 NAME (Company or Facility) SIMPSON PAPER COMPANY DBA—Doing Busimm N) PHYSICAL LOCATION 942 SOUTH STOCKTON AVENUE FF"DTSC Use Only CITY RIPON CAZIP 95366 ?761gion COUNTY SAN JOAQUIN CONTACT PERSON DENNIS ABRAHAMSON PHONE NUMBER(209 ) 599 - 0275 First Name) llaa Nano) DTSC 1772 (1/93) Page I