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stau of California - California F�tinmmenrul Prolatioo Agency Department or Toric Sulrtrcea Control <br /> Ch«t Number v Page 1 of 6 <br /> 69643 <br /> °' ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> ELFACILITY SPECIFIC NOTIFICATION <br /> MAR For Use by Hazardous Waste Generators Performing Treatment 0 initial <br /> U M 2 � ' Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> E!WONMENTAL HEFT!TH and by Permit By Rule Facilities <br /> a PgMITOEPVICLS <br /> h ease r er to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> I notification form, DISC 1772. You must attach a separate unit specific not ficarion form for each unit at this location. ]here are <br /> different unit specific notification forms for each ofthefour categories and an additional not ficaion form for transportable treatment <br /> units (77U'r). You only have to submit forms for the der(s) that cover your unit(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 /> Pageo <br /> _ f_'• 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 the appropriare 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 S timer$1,140. lfyou 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. NOTIT7CATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notification forms you must attach. <br /> Conditionally Eaottpt Small Quatuiry Treatment operations may not operate unity under <br /> Per any other tiwr. <br /> Number of units and attached unit specific notifications <br /> Fee per Tier <br /> A. Conditional) Exem t-Small mor per� t) <br /> Y P Quantity Treatment (Porto DTSC I772A) S 100 <br /> B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 17728) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. =a<Permit by Rule (Form DTSC 1772D) <br /> 51,140 <br /> 1 Total Number of Units Total Fee Attached S a 100. <br /> If. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAI, Q Q _Q _I O 7 7 1 2 BOE NUMBER (if available) H GHQ3_Q 4 2_1 <br /> NAME (Company or Facility) LODI MEMORIAL HOSPITAL WEST <br /> (DBA—Dona Business As) <br /> PHYSICAL LOCATION 800 S. LOWER SACRAMENTO ROAD <br /> P.O_ BOX 3004 <br /> CiTYFur DTSC UA Only <br /> LODI CA ZiP 95241 - 1908 <br /> Region <br /> 'OUNTY SAN JOAQUIN <br /> CONTACT PERSON e "' DENNIS MARLOW PHONE NUMBER( 209) 368 - 6654 <br /> (Fire Name) (LW Name) <br /> -n3 <br /> )TSC 1772 (1/93) 1Page 1 <br />