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Suite of Califonsio-California Envi oomeota xection Agem.y Department of Tone Substantia Control <br /> cnut amber Page l of IL <br /> 19768 g 2 00 0 1 5 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> Qx For Use by Hazardous Waste Generators Performing Treatment ® Initial <br /> UUnder Conditional Exemption and Conditional Authorization, ❑ Revised <br /> y and by Permit By Rule Facilities <br /> C <br /> Q <br /> tt Please refer to the attached Instructions before completing this form. You may norms far more than one permitting tier by using this <br /> notification form, DISC 1772. You must attach a separate unit specific notification farm for each unit at this location. There are <br /> different unit specific norif cation forms for each of the jour categories and an additional norifcation form for transportable treatment <br /> units (7TU's). You only have to submit forms for the tier(s) that cover your unii(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 notification will not be considered complete without payment of rhe appropriate fee for each tier under which you are operating. <br /> (Please note that rhe fee is per TIER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, <br /> you only owe $1,140, NOT 5 tiny$1,140. Ifyou 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 /> 1. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notifcation 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 Fee per Tier <br /> rent per unit/ <br /> A. X_ Conditionally Exempt-Small Quantity Treatment (Form DTSC I772A) $ 100 <br /> Ox'�t Sc(�, <br /> B. Conditionally Exempt-Spec ed7st+ aragrnoPs (Form DTSC I772B) S 100 <br /> F p <br /> C. Conditionally Authori /�N%( orm DTSC 1772C) $1,140 <br /> D. Permit by Ruleo°"m � (Form DTSC 1772D) $1.140 <br /> (a 4°�/° <br /> I Total Number of Units 9yFN /u°°3 Total Fee Attached $100.00 <br /> Tp <br /> If. GENERATOR mENfIFICATION <br /> EPA ID NUMBER CA L 9 1 2 2 0 3-3-3 8 _ BOE NUMBER (if available) H_HQ_ <br /> NAME (Company or Facility) STOCKTON RADIOLOGY MED GRP INC <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION 161 7 N- ('Ai TPnRNTA SUTTF 1 A <br /> For DTSC C,e Only <br /> CITY STOCKTON. CA ZIP 95204 <br /> Region <br /> 'OUNTY SAN JOAQUIN COUNTY <br /> CONTACT PERSON THOMAS THOMAS PHONE NUMBER209 ) 948 -6063 <br /> (Fins Name) (t,u Name) <br /> NOTIFICATION MADE BECAUSE OF ANTICIPATED PURCHASE <br /> DTSC 1772 (1/93) OF RECYCLING UNIT. Page I <br /> VALsta _ c ;-c�Q i <br />