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Sub of Califorcm-Califorau Furmoommral PrvtwtKm Agawy Dgosu"m of Tone SuWraoraa C <br /> Cheer Nunmer Page l O <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION — / <br /> i <br /> For Use by Hazardous Waste Generators Performing Treat eit� Ley Initial <br /> U Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> 3 <br /> r7r Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> notification farm, D7SC 1772. You mart attach a separate unit specific notificationform for each unit at this location. Thee are <br /> different unit speditc norification forms for each of the four categories and an additional noriftcarnon form for transportable treatment <br /> units (771'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 notfrcation package and indicate the total number of pages at the top of each page at the <br /> 'Page _ of_'. Pru your EPA ID Number on each page. Please provide ail of the information requested, all ftelds must be <br /> completed excepr those that state 'if different' or 'if available'. Please type the information provided on this form and any <br /> attachments. <br /> The norification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. <br /> (Please note that rhe fee is per ITER 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.) Cheats 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 /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific noriftcation formr you must attach. <br /> Conditionally Exempt Small Quanray Treatment operctioar may rr�operme units under any other rier. <br /> Number of units and attached unit specific notifications Fm per Tier <br /> (AN P-st—) <br /> A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 <br /> B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> Total Number of Units Total Fee Attached S U V Ul <br /> Q. GENERATOR IDENTIFICATION a <br /> EPA ID NUMBER CAL FI L' ( 1 - BOE NUMBER (if available) H�HQa <br /> ��0 ! Q- 5 7 <br /> NAME (Company or Facility) f1�Q lLYL1Y� MITA �p <br /> (DBA—Doing&uimw As) <br /> PHYSICAL LOCATION �i f rk r_ (_ U .qj <br /> CITY CA ZIP For DTSC Ute Omy <br /> QC� I � iF� <br /> Region <br /> COUNTY <br /> CONTACT PERSON � � ��!� y �ir ✓, PHONE NUMBERC 1 5 _ <br /> (rim Na") - (Ln Na – �— <br /> DTSC 1772 (1/93) Page 1 <br />