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Chak Numbr Page "f 7 2 00012 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Haardous Waste Generators Performing Treauntat ® Initial Under Conditional Exemption and Conditional Authorization, ❑ Revised and by Permit By Rule Facilities Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are different unit specific notification forms for each of the four categories and an additional notification form for transportable treatment units (77TI's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. Number 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 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 is per 77FR not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, you only owe$],140, NOT 5 timer$1,140. If you operate any Permit by Rule units and anv units under Conditional Authorization you owe$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you must attach. Conditionally Eze mpt SmaU Quantity Trearrou operations may not operate units under airy other tier. Number of units and attached unit specific notifications Fee per Tier (rot per=i) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) S 100 B. 1 Conditionally Exempt-Specified Wastestreant (Form DTSC 1772B) S 100 1 ,1"—_0 M C. Conditionally Authorized m E W p rl(Form DTSC 1772C) $1,140 y D. --—Permit by Rule I �� -i rr (Form DTSC 1772D) —————_$1.140 ' cY _- V 1 Total Number of Units`. " Total Fee Attached S 100 ? `i,t U. GENERATOR IDENTIFICATION-,��,-' EPA ID NUMBER CA D063036776 BOE NUMBER (if available) H_HQ _ NAME (Company or Facility) Pacific Coast Producers (DBA—Doing Buamas Aa) 32 E. T o k a y Street PHYSICAL LOCATION For DTSC Ute CrJv C�� Lodi CA ZIP 95240 Region COUNTY San Joaquin CONTACT PERSON Bob Paulat PHONE NUMBER2( 09 ) 334 _ 3352 (First Name) (lac Name) DTSC 1772 (1193) Page 1