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kC, <br /> of n-California£arumm®ul Protection Agency Department of Toac <br /> Suhtaaca Control <br /> Page I of_'_1 <br /> S O TE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> r For Use by Hazardous Waste Generators Performing Treatment ❑ Initial <br /> IUnder Conditional Exemption and Conditional Authorization, ❑ Renewal <br /> and by Permit By Rule Facilities Ammdmmt <br /> Please refer to the attached Instructions before completing this jorm. You may notes for more than one permitting tier by using this <br /> not(cation form, D7SC 1772. You must attach a separate unit specific not fearlon form for each unit at this location. There are <br /> different unit specific not f cation forms for each of the four categories and an additional tot f cation form for transportable treatment <br /> units (79U's). You only have to submit jormr for the tier(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; aU 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 fees are assessed on the basis of the number of tiers the notifier will operate under, and will be collected by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE TV7M THIS NOTIFICATION FORM <br /> I. NOTIFICATION CATEGORIES <br /> Indicate rhe number of units you operate in each tier. This will also be the number of unit spec fe not(cation forms you murk attach. <br /> Conditionally Exempt Small Quantity Treatment operations may not operate units under any aper tic. <br /> Number of units and attached unit specific notificatiorls for.each tier reported. <br /> A. Conditionally Exempt-Small Quanti �Tie aiment D. Permit by Rule <br /> B. xx Conditionally Exempt-Specified gasteslr�rpA, E. Commercial Laundry <br /> C. Conditionally Authorized 1 61995 F. Variance (Section 25143) <br /> if. GENERATOR IDENTIFICATION J, t <br /> I <br /> EPA ID NUMBER CA 0 0 0 0 2 5 91 8 4 �c9AlfpatTt) '' <br /> — — — — —— — — — ED MBER (if available) H AH 3 6 0 2 7 5 3 3 <br /> FACILITY NAME Dameron_Hosnital Assotia <br /> (DBA-Doing 8ucineu N) <br /> PHYSICAL LOCATION 525 West Acacia Street '. <br /> CITY Stockton CA ZIP 95203 - 2484 <br /> COUNTY San Joaquin <br /> CONTACT PERSON Mark G. Koenig PHONE NUMBER 209 944 - <br /> (Firm Nurse) (tact Nam ) <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME <br /> or DISC U ONy <br /> STREET <br /> Region <br /> CITY STATE _ ZIP <br /> COUNTRY <br /> USA) <br /> (oNy complue if= <br /> CONTACT PERSON PHONE NUMBER) <br /> (Fit-Ncme) (LAA Neme) . <br /> DTSC 1772 (1/95) <br /> Poor 1 <br />