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` •- State of Cntifornia-CaliMornia EurironmeaW Frowdoo <br /> Agency 1?epatriaeot of Toric Subetaaea Control <br /> Page 1 of <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment ❑ Initial <br /> Under Conditional Exemption and Conditional Authorization, ❑ Renewal <br /> and by Permit By Rule Facilities Ameadmeat <br /> Please refer to the attached Instrucrions before completing this form. You may notify 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 four categories and an additional notification form for transportable treatment <br /> units (TTU'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 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 notiftcarion 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 SEND YOUR FSE W=THIS N07ZFTCA7701V 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 /> Conditionally 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. 1 Permit by Rule <br /> B. Conditionally Exempt-Specified Wastestream E. Commercial Laundry <br /> C. Conditionally Authorized F. Variance (Section 25143) <br /> Ii. GENERATOR IDENTIFICATION / / <br /> EPA ID NUMBER CAS 1�Q Q Q g _ BOE NUMBER (if available) H_HQ3 6 0 3 6 <br /> FACILITY NAME 01k6(Ad),1 <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION J-.-S 7 V- A&, s f1 y- - 11 <br /> '�Gt AC DVI. <br /> CITY Mao I -eca = CA ZIP 9 5-3 3 b <br /> COUNTY CA A o (� <br /> CONTACT PERSON I V' V 1/'V� PHONE NUMBER 2 3 9- 3 1 <br /> n- <br /> (Firm Name) (last Name) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME For DISC Use Only <br /> STREET <br /> Region <br /> CITY STATE ZIP - <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON PHONE NUMBER(___)_= <br /> (First Name) (USE Name) <br /> DTSC 1772 (1/95) Page 1 <br />