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Slate o(Cali(ornia-Calitornia Fayvoawm at&'s Protection Agency - MAR rt 1993�Parnsm`or Toric SuEnaoces C." Check Number Page l of ENVIRONMENTAL HEALTH JqA071Q PERMIT/SERVICES ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM C` FACILITY SPECIFIC NOTIFICATION For Use by Hazardous Waste Generators Performing Treatment )kr Initial U Under Conditional Exemption and Conditional Authorization, ❑ Revised r°J and by Permit By Rule Facilities 5 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 specific not(cation form for each unit at this location. There arc different unit specific not f carion jorms for each of the jour categories and an additional nor(cation form for transportable treatmenr units fTTU's). You only have to submit forms for the lier(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 S units but they are all Conditionally Authorized, you only owe $1,140, NOTS firrses$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 notif cation forms you must attach. Conditionally Ezonpt Small Quantity Treatment operations may not operate unw ruder any other tier. Nrunber or units and attached unit specific notifications Fee per Tier ,not per unit) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) $ 100 B. Conditionally Exempt-Specified Wastestream (Form DTSC I772B) $ 100 C. Conditionally Authorized (Form DTSC 1772C) 51,140 D. Permit by Rule (Form DTSC 1772D) $1,140 Total Number of Units Total Fee Attached S100 11. GENERATOR IDENTIFICATION EPA ID NUMBER CAD 0 4 1 B 4 0 0 0 2 BOE NUMBER (if available) H A HQ3 6 0 2 7 5 3 3 NAME (Company or Facility) MBA-Doing Businesa As) PHYSICAL LOCATION DAMERON HOSPITAL ASSOCIATION 525 WEST ACACIA STREET STOCKTDN 7R�eion U.e Only CITY CA ZIP 95203 � 'OUNTY SAN JOAQUIN CONTACT PERSON THOhIAS BECK PHONE NUMBER( 209 )461 - 3176 (Fina Name) (Lau Name)