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a ursilsr Gt t�Jf ( ) 5 Page i ora - ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment Initial Under Conditional Exemption and Conditional Autborintion, ❑ Revised and by Permit By Rule Facilities C t7i Please refer to the attached Instructions before completing this form. You may noth for more than one permitting tier by using this notification form, DTSC 1772. You must attach a separate unit sptcoc rwti�catlon form for each unit at this location. There art different unit tpecfc notication forms for each of the jour categories and an additional notication form for transportable treatment units (TM's). You only have to submir forms for the tiers) that cover your unit(s). Discard or recycle the other unused forms. Number each page of your completed not(cation package and indicate the total number of pages at the top of each page'at the 'Page _ oj_'. Put your EPA ID Number on each page. Please provide all of the information requested; all fields must be completed except those that stare 'if different' or 'if available'. Please type the,information provided on this form and any attachments. The notification will not be considered complete without pmment of the appropriate fee for each tier under.which you are operating. (Please note that the fee is per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized. I you only owe 31,140, NOT times $1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe$1,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top of this form. Please write your EPA ID Number on the check. Fill in the check number in the box above. I. NOTIFICATION CATEGORIES Indicate the number of units you operate in each tier. This will also be the number of unit speck noticarion forms you must attach. 1 Conditionally Exo pt Small Quatuity Treatment operations may not operase units under any other tier. Number of units and attached unit specific notifications "Je Servrj-c. a per Tier A. ' Conditional) Exem t-Small �O Operations rnorpu wut Y P Quantity Treatment (Form DTSC 1772A) •c5c�� _.i\ S 100 . _ r- r 1 I B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 177213) i-p ei S 100 JUN 2 9 1993 C. Conditionally Authorized (Form DTSC 1772C) 51,140 babuta ces°cant u1 D. Permit by Rule (Form DTSC 1772D) 51.140 1 Total Number of Units Total Fee Attacbed S 100.00 11. GENERATOR EDEN-17MCATION EPA ID NUMBER CA L 0 0 0 3 1 1 5 BOE NUNIBER (if available) H FHQ 3 8 0 0 1 9 7 0 NAME (Company or Facility) Delta Radiology Medical Group, Inc. (DBA—Doing Susineu As) PHYSICAL LOCATION 541 S. Ham Lane, Suite B Fur DTSC L: < O-:y CITY Trrli CA ZIP 95240 R<r�nn I OUNTY San s oacruin CONTACT PERSON Orlin Koehrstedt PHONE NUMBER( 209 466 • 5027 (Fent NraY) (Liu Ns.n ) UT r4 45016� �.G.