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State of CWornia-California Environmee - Protettiou Agency Department of Toxic Substances Control <br /> Check Number <br /> l � l D/ Page 1 of <br /> i 93 00 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment •� Initial <br /> V Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> C and by Permit By Rule Facilities <br /> d <br /> yPlease refer to the attached Instructions before completing this form. You may notes for more than one permitting tier by using this <br /> notification form, DISC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notification forms for each of the jour categories and an additional not fcatlon form for transportable treatment <br /> units (777J'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 6e <br /> completed except those that stare '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 for each tier under which you are operating. <br /> (Please note that the fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT 5 tinter$1,140. lfyou 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 /> I. 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 Emnpt Small Quantity Treatmeru operations may not operate un' n a tier. <br /> 0 Service <br /> Number of units and attached trait specific notifications y`p�Operations S@/�4 Fee per Tier <br /> C 0��• /rot per unit) <br /> A. Conditionally Exempt-Small Quantity Treatment (F rt TSC 1772A) 0 $ 100 <br /> �9j q 1993 <br /> B. Conditionally Exempt-Specified Wastestream ( D'Fb`CI772B) $ 100 <br /> C. Conditionally Authorized (Fo DTSgT^".c <br /> $1,140 <br /> D. -Permit by Rule (Form D 147LI44 $1,140 <br /> Total Number of Units Total Fee Attached $ <br /> II. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAS j y ? L_ip i Z j BOE NUMBER (if available) H_HQ_- <br /> - —— ——— <br /> NAME (Company or Facility) c;-1-6n� <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION <br /> S I For DTSC Use Only <br /> CITY 7✓C " '- J CA ZIP �I�LJ� - I <br /> Region <br /> COUNTY <br /> CONTACT PERSONi <br /> (P�JN PHONE NUMBER(1 „ ) ' � , - <br /> (First Name) (tan Name) <br /> DTSC 1772 (1/93) <br /> Page I <br />