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Sett of Califoria-California Enviroommml Prouctioa Agency Department or Toxic Substance Control <br /> Ck:wt umbo -` Page 1 of 6 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFI-CATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Perfotvung Treatment Initial <br /> j Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> and by Permit By Rule Facilities <br /> Z <br /> j Please refer to the attached Instructions before completing this form. You may not fy for more than one permitting tier by using this <br /> notification form, DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific nor f cation forms for each of the four categories and an additional not f cationform for transportable treatment <br /> units (77U's). You only have to submit forms for the rier(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 /> 'Page _ of_'. 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 the fee is per 77ER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> you only owe $1,140, NOTS timer $1,140. Ifyou 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 0 Number on the check. Fill in the check number in the box above. <br /> 1. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific nor f cation forms you must attach. <br /> Conditionally Exonpt Small Quantity Treatment operations may not operate units under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> rnw per unu) <br /> A. S Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) (addition) S 100 <br /> B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) $ 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) 51,140 <br /> D. Permit by Rule (Form DTSC 1772D) $1,140 <br /> 7 Total Number of Units Total Fee Attached $ 0 <br /> If. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CAL 0 0 0 0 4 3 0 7 8 BOE NUMBER (if available) HA HQ3 6 0 2 1 5 8 1 <br /> NAME (Company or Facility) LODI MEMORIAL HOSPITAL HAM LANE CLINIC <br /> (DBA—Dont Business Ar) <br /> PHYSICAL LOCATION 123S west Vine Street <br /> P.O_ Box 3004 <br /> For DTSC U.c Onl, <br /> CITY LODI CA ZIP 95241- <br /> Repon <br /> 'OUNTY SAN JOAQUIN <br /> CONTACT PERSON DENNIS MARLOW PHONE NUMBER(209 ) 339-7573 <br /> (Fine Namc) (Lass Namc) <br /> DTSC 1772 (1/93) Page I <br />