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State o,CaUfornia-California Environmental Pr" !tion Agency Department of Toric Substances Control Check Number Page 1 of 3 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment Initial U Under Conditional Exemption and Conditional Authorization, ❑ Revised and by Permit By Rule Facilities y` Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this notification form, DTSC 1772. You must attach a separate unit speck norif cation form for each unit at this location. There are different unit specific notif cation forms for each of the four categories and an additional notif cationform for transportable treatment units (ITV's). You only have to submit forms for the tier(s) that cover your unit(s). Discard or recycle the other unused forms. Number each page of your completed notification package and indicate the total number of pages at the top of each page at the 'Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requested; all fields must be completed except those that state 'if different' or 'if available'. Please type the information provided on this form and any attachments. The notification will not be considered complete without payment of the appropriate fee for each tier under which you are operating. (Please note that the fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, you only owe $1,140, NOT5 timer$1,140. If you operate any Permit by Rule units and any units under Conditional Authorization you owe$2,280.) 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 specific notication forms you must attach. Conditionally Exempt Small Quantity Treatment operations may not operate unitt under any other tier. Number of units and attached unit specific notifications Fee per Tier (nor per wur) A. Conditionally Exempt-Smil Quantity Treatment (Form DTSC 1772A) $ 100 B. 2 Conditionally Exempt-Specified Wast S ( DTSC 1772B) $ 100 d c C. Conditionally Authorized 2�Y� �°°�� (Form SC 1772C) $1,140 O D. Permit by Rule 3m�°�a0 �`v� (For».),T C 1772D) $1,140 2 Total Number of Units Total Fee Attached $ 1 oo fl. GENERATOR IDENTIFICATION ��01d tpi EPA ID NUMBER CAD 0 0 0 3 2 0 2 6 7 BOE NUMBER (if available) HF HQ3 8 0 0 1 3 2 _4 NAME (Company or Facility) San Joaquin General Hospital (DBA—Doing 13uarneu A') 500 W. Hospital Road PHYSICAL LOCATION For DTSC Use Only CITY French Camp, CA ZIP 95231 - R<gion COUNTY San Joaquin CONTACT PERSON Steven Ebert PHONE NUMBER 2 9 468 -66i ) (First Name) (Litt Name) DTSC 1772 (1/93) Page 1