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State of California-California Fatrimounent `rotectiooenc <br /> Ag Y Department of Toric Soheuoees Control <br /> Check Number �- <br /> .� ,. _. Page 1 of 1C <br /> . Ul9so � <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTfV1URfION FORM <br /> FACILITY SPECIFIC NOTIFICATIOXVI M!:% r' <br /> aeM1 f t.: i `Ci <br /> For Use by Hazardous Waste Generators Performing '�reh� - ® Initial <br /> U Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> 3 <br /> c j Please refer to the attached Instructions before completing this form. You may notify jar more than one permitting tier by using this <br /> notification form, OTSC 1772. You must attach a separate unit specific not(cation form for each unit at this location. There are <br /> different unit specific notification forms for each of the four categories and an additional notification form for transportable treatment <br /> units (77V 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 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 will not be considered complete without payment of the appropriate fee far each tier under which you are operating. <br /> (Please note that the feels 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 /> L NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific not(cation forms you must attach. <br /> Conditionally Ere npt Small Quantity Treatment operations may not operate ulnas under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> (rot per unit) <br /> A. 0 Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. 1 Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. 0 Permit by Rule (Form DTSC 1772D) $1,140 <br /> 2 Total Number of Units Total Fee Attached $ 1 t 240 <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA D 9 8 1 3 8 7_7_4 9 BOE NUMBER (if available) H_FHQ3_$Q _Q 1 _fi _2_9 <br /> NAME (Company or Facility) Lustre-Cal Nameplate Corp. <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 1 10 Fast Ttirnpr Road <br /> Foc DTSC Use Only <br /> CITY Lodi CA ZIP 99240 - <br /> Region <br /> COUNTY San Joaquin <br /> CONTACT PERSON Rod Hunter PHONE NUMBER <br /> (209 ) 4_ 3_ <br /> (First Name) (Lau Name) <br /> DTSC 1772 (1/93) Page 1 <br />