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ONSITE ( SWASTE TREATMENT N �'IF . kI1d�` w <br /> 1 FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Tre mend APR �Am <br /> Under Conditional Exemption and Conditional Authorizati n, U5 �99fj <br /> G and by Permit By Rule Facilities <br /> Please refer to the attached Instructions before completing this form. You may notify for more r �KLP rt ' er using U. <br /> notification form, DISC 1772. You must attach a separate unit specific notification form for each } on. There an <br /> different unit specific notification forms for five of the categories and an additional notification form for transportable treatment units <br /> (I=s). You only have to submit forms for the tier(s)1bategory(ies) that cover your unit(s). Discard or recycle the other unused <br /> forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at <br /> the '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 highest tier the notifier will operate under and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE PAYMENT WITH THIS NOTIFICATION 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 <br /> must attach. Conditionally Exempt Small Quantity Treatment operators 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 (CESQT) D. — Permit by Rule (PBR) <br /> $,K—Conditionally Exempt-Specified Wastestream (CESW) E. — CE--Commercial Laundry (CE-CL) <br /> C. Conditionally Authorized (CA) F. Conditionally Exempt-Limited (CEL) <br /> II. GENERATOR IDENTIFICATION `L. <br /> EPA ID NUMBER CAD `� ( 669t '&_q_q�D BOE NUMBER (if available) HYHQ_ (e Q .I S Let <br /> FACILITY NAME f5y%3 — K0L4%v%t.t_Mo e.rnv%.A J AGk 04 CA +-111 <br /> (DBA—Doing Business As) 1� <br /> PHYSICAL LOCATION t{ 9 'R -7 104-e S+Lq Lyil_ / <br /> CITY kO CCA ZIPS S'Ad- 0, <br /> COUNTY g pt v� j o c,q ✓\ `,,D <br /> CONTACT PERSON f�V.SS� �C.0 ayl <br /> \\ i Q 1\ PHONE NUMBER(a I5)Z Z <br /> (First Name) (last Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME VFM GSo 3 — M M d J e t-j <br /> STREET 31\\\ We_-&� AARA \ hti Rll2-VLiJe— <br /> CITYvuJF�QXp�n�A STATE P 4h ZIP 191'32.- <br /> . r — <br /> COUNTRY <br /> (oNycomplete if tat USA) r <br /> CONTACT PERSON Rotg��(1 1.tce:(arde k`O PHONE NUMBERQV; ) 21-1 -919, <br /> (First Name) (last Name) <br /> DTSC 1772 (1/96) Page 1 <br />