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State of California-California Fariioomental Pr ion Agewy Departmeat of Toric Substances Control <br /> Page, 1 of 6 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION ���' <br /> For Use by Hazardous Waste Generators Performing Treatment .. wytiat <br /> Under Conditional Exemption and Conditional Authorization, <br /> L RBnewal <br /> and by Permit By Rule Facilities ❑ Revision <br /> Please refer to the attached Instructions before completing this form. You may notes for more than�Oge'be?tkfN6l$�tI using this <br /> notification form, DISC 1772. You must attach a separate unit specific notification form for each unci a17hiYtocaation. There are <br /> different unit specific notification forms for each of rhe four categories and an additional notification farm for transportable treatment <br /> units (77TTs). 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 fees are assessed on the basis of the number of tiers the notifier will operate under, and will be collected by the State <br /> Board of Equalization. DO NOT SUP YOUR FEE W7777 7WS N077ICA77ON 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 must attach. <br /> Canduzonally Exempt Small Quantity Treatment operations 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 D. Permit by Rule <br /> B. 1 Conditionally Exempt-Specified Wastestream E. Commercial Laundry <br /> C. Conditionally Authorized F. Variance (Section 25205.7) <br /> II. GENERATOR IDENTIFICATION F <br /> EPA ID NUMBER CAD 0 0 9 1 4 0 12 0_ � BOE NUMBER (if available) H AHQ 3 L L06 9 3 5_ <br /> FACILITY NAME MARLEY COOLING TOWER COMPANY <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 150 N SINCLAIR AVE <br /> CITY STOCI:TON CA ZIP 95215 / <br /> COUNTY SAN JOAQUIN <br /> CONTACT PERSON DAVID LIEB PHONE NUMBER( 209) 465-3451 <br /> (Fins Name) (Lt Neme) <br /> MAILING 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) (LAI Name) <br /> DTSC 1772 (7/94) <br /> Page I <br />