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tio <br /> oa <br /> 22 3" y,s•,o 8 2 O !f 0 5«1 o ASeacy Department of To,& suea.nrn coat <br /> « 3 <br /> Number G t D - - Page 1 of 3 <br /> .. <br /> 1 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment Initial <br /> U Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> i:3— <br /> tj Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> notification form, DTSC 1772. You must attach a separate unit specific not fcation forth for each unit at this location. There are <br /> different unit specific riotificationforms for each of thefour categories and an additional not fcationform for transportable treatment <br /> units (TTU's). You only have to submit forms for the tiers) that cover your unit(s). Discard or recycle the other unused forms. <br /> Number each page of your completed not f cation package and indicate the total number of pages at the top of each page'ar 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 pavmenr of the appropriate jet for each tier under which you are operating. <br /> (Please note that rhe fee is per T7ER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized. <br /> -you only owe$1,140, NOT S times$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe 52,280.) 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 nt f cation forms you must attach. <br /> Conditionally F_ronpt Small Quantify Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> A. ConditionallyExempt-Small ,nor penis„ <br /> p Quantity Treatment (Form DTSC 1772A) S 100 <br /> B. 1 Conditionally Exempt-Specified,Was earn (Form DTSC 17728) S 100 <br /> C. Conditionally Authorized' ^rs n (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) 51,140 <br /> 9 1993 <br /> 1 Total Number of Uni6s Total Fee Attached S 100.00 <br /> if. GENERATOR IDENTITICATiON vc• <br /> �.ecountlo9 <br /> EPA ID NUMBER CAL 0 0 0 0 .6 3 _ BOE NUMBER (if available) HE HQO B_tZ 4 L O 1 Q <br /> NAME (Company or Facility) Delta Radiology Medical Group, Inc. <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION' <br /> 2420 N. California Street, State 7 <br /> CiTY StocktonCA ZIP 95204 Fur D:SCIL: Only <br /> nsr•nn <br /> .OUNTY San Joaquin <br /> CONTACT PERSON Orlin Koehmstedt PHONE NUMBER( 209 ) 4F5 5027 <br /> (F.m Nsmc) (LAm Nsmt) <br /> DTSC 1772 (1/93) U� C,; 1 ' 1. F A l r Page t <br />