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EPA ID NUMBER CAL000063117 Page 2 of 3 , MAILING ADDRESS, IF DIFFERENT: i COMPANY NAME (DBA) Delta Radiology Medical Group, Inc. STREE 1121 West Vine St. ) Suite 15 CITY Lodi STATE Ca ZIP 95240 - COUNTRY (only complete if nor LSA) CONTACT PERSON Nita KEfftp PHONE NUMBER( 209) 369 -8261 (First Name) _ (Lu Name) III. TYPE OF COMPANY: STANDARD rNDUSTRIAL CLASSIFICATION (SIC) CODE: Use either one or two SIC codes (a jour digit number) that best describe your company's products, services, or industrial activin. Example: 7384 Photortnishinc lab 3672 Printed circuit boards First: 8011 Radiology office Second: IV. PRIOR PERNHT STATUS: Check yes or no to each question.- ITS uestion:YES NO ❑ ® 1. Did you file a PBR Notice of Intent to Operate (DTSC Form 8462) in 1992 for this location? ❑ ® 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim status for any of these treatment units? ❑ ® 3. Do you now have or have you ever held a state or federal full perrrit or interim status for any,other hazardous waste activities at this location? ❑ ® 4. Have you ever beld a variance issued by the Department of Toxic Substances Control for the treatment you are now notifying for at this location? ❑ ® 5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator? V. PRIOR ENFORCEMENT HISTORY: Not rrquired from generators only noting as conditionally ezanpr. YES NO ❑ ❑ Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or final orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health enforcement agency? (For the purposes of this form, a notice of violation does not constitute an order and need not be reportod unless it was not corrected and became a final order.) ❑ If you answered Yes, check this box and attach a listing of convictions,judgments, settlomeats,or orders and a eof of the cover sheet from each document. (See the Instructions for more information)