COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

State"if CaGforou- Catitoruia F�rirowneacal P tion .Agency Departm®t of Toric Subataoca Control Chick Number L//(7 � \/' �J Page I of 7 n16350 9 2 0 0 0 () 5 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORAI FACILITY SPECIFIC NOTIFICATION ;e For Use by Hazardous Waste Generators Performing Treatment ® Initial J Under Conditional Exemption and Conditional Authorization, ❑ Revised and by Permit By Rule Facilities C tit Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this notification farm, DTSC 1772. You must attach a separate unit specific not ficatton form for each unit at this location. There are different unit specific noriftcation forms for each of the four categories and an additional nothcation form for transportable treatment units (77V s). You only have to submit forms for the tiers) 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 ofpages 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 TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, you only awe$1,140, NOT S 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 write your EPA ID ,Number on the check. 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 Exempt Small Quantity Treatment operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier (run per uNq A. Conditionally Exempt-Small Qu )enorm DTSC I772A) S 100 B. 1 Conditionally Exempt-S ified Wastesorm DTSC 1772B) S 100 C. Conditionally Authori e`" orm DTSC 1772C) $1,140 D. Pezmit by Ruleorm DTSC 1772D) 51,140 Td I Total Number of Units Total Fee Attached $ 100.00 11. GENERATOR IDENTIFICATLON EPA ID NUMBER CAD 1 1 5 0 9 2 0 2 5 BOE NUMBER (if available) HA HQ 3 6 0 4 5 4 2 7 NAME (Company or Facility) Van den Bergh Foods Company (DBA—Doing Business As) PHYSICAL LOCATION 1400 Waterloo Road For DTSCllfise Onty CITY Stockton CA ZIP 95205 Region_ COUNTY San Joaquin CONTACT PERSON Frank Yoneshige PHONE NUMBER( 209 ) 466 - 9580 (First Name) (Loa Neme) DTSC 1772 (1/93) Page 1