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r r t Paye 1 of 3 <br /> r <br /> t i <br /> ONSITE HAZARDOUS «ASTE TREATMENT NOTIFICATION FORA! <br /> FACILITY SPECIFIry, C3TTI <br /> NFICATION <br /> For Use by Harardd(is }ti/^utt&Kerattoors Performing Treatment Treat <br /> y ` ❑ Initial ' <br /> Under Conditional Exemption and Conditional Autboriratioa, <br /> ❑ Revised <br /> and by Permit By Rule Facilities 1 <br /> i <br /> Please refer to the attached Instructions before completing this form. You may notiAjor more than one pgrmirring tier by using this <br /> notification form, D7SC 1772. You must attach a separate unit speck not cation form jor each unit a r this location. There are <br /> different unit spccc no7icarionjamtsjor each ofthefour categories and an additional notifi for tranrporrabfe treatment <br /> units (TTU i). You only have to submit forms for the tiers) that covyr your unit(r). Discard or recycle the other unused foment <br /> Number each page of your completed norifrcarion package and indicate rhe total number ocard ofPagej at the e t he thele unusePage' t the <br /> Page _ oj_'. Put your EPA ID Number on tach page. Please provide all of the injprmation requested all fields mart be <br /> completed except those that state 'if cifferent' or 'if available'. Please type th <br /> attachments. ,e,information provided on this form and any <br /> The notification will not be consideredcomplete with <br /> (Please note that rhe jet is per 77ER77ER Im <br /> out pment of the appropriate fee jor each tier under which you are operating. <br /> not per UNIT. For example. if you operate S units but they are all Conditionally Authorized, <br /> you only owe 51,140, NOT S rimer $1,140. If you operate any Permit by Rule units and any units under Conditiorwl Authorization <br /> you owe $2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top ofthis <br /> jotm. Please write your EPA ID Number on the check. Fill in the check number in the box above. <br /> 1. NOTIFICATION CATEGORIES <br /> Indicate the number of unks you operate in each tier. This will also be the number of unit speck notrficationforms You must attach. <br /> Conditionally Eranpt Small Quantity Trewment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications <br /> Fee per Tier ; <br /> A•. ^_ Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) r�rr"1O 11I <br /> S 100.' <br /> B. _1 _ Conditionally Exempt-Specified Wastestream <br /> 9�t (Form DTSC 1772B) S 100 '' <br /> C. Conditionally Authorized (Form DTSC 1772C) <br /> $1,140 ' <br /> D. — Permit by Rule <br /> o o a (Form DTSC 1772D) $1.140 <br /> 1 Total Number of Units <br /> Total Fee Attached S 100.00 <br /> II. GENERATOR P.E TIFMCATION <br /> EPA ID NUMBER CAS IZQ__ k 0 6 3 1 1 6 •'BOE NUMBER (if available) H FHQ3. •8' 0 0 1 9 7 0 <br /> NAME (Company or Facility) tial t-a Radiology Medical Group I — <br /> (DBA-Doing Busimu Ar) Inc <br /> - <br /> PHYSICAL LOCATION <br /> 1121 W. Vine St. , Suite 15 <br /> CITY Lodi CA 2IP 95240 Fu=,:"OUNTY Regj <br /> q=n 7�}�rn tin <br /> 1 <br /> CONTACT PERSON Orlin Koeknstedt PHONE NUMBER( 209 ) 466 . 5027 <br /> (Fico Nrrtn) (Vu Hams) f!! <br /> DTSC 1772 (1193) - 1 <br /> p,-, t <br />