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state or c>alifo,a;,.California F�.iro wW protecboa Age JUN 1 1995 <br /> neart-e>ot of Toac s'kar,aee,Cmtrd <br /> ENVIRONMENTAL HEALTH Pa96 1 of <br /> ONSITE HAZARDOUS WASTE T i1 NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment <br /> Under Conditional Exemption and Conditional Authorization,- El �� <br /> 13 Renewal <br /> and by Permit By Rule Facilities <br /> ® Amendment <br /> Please refer to the attadud Instructioru before completing this form. You may notes for more than one permitting ing <br /> tier by ru <br /> notification form, DISC 1772. You must attach a separate unit speck notOcation form for each unit at tlrit lothis <br /> different There are <br /> different unit specific notification forms for each of the four categories and an additional noticadon form for transportable ireatmenr <br /> units (PIU:s). You only have to submit forms for the tiers) that cover your unit(s). Discard or recycle the ober unused fog. <br /> Number cock 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 m Number on each page. Please provide all of the information requested; allfields must be <br /> completed except those that state 'if different' or 'if available'. Pleat type the information provided on thisform and anv <br /> attachments. <br /> The notification fees are assessed on the basis of the number of tiers the notifier will operate under, and will be collecred by the State <br /> Board of Equalization. DO NOT SEND YOUR FEE WTM 7717S N077FICA770N FORM. <br /> 1• NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. 7hiv will also be the number of unit speck notiflcationjorms you must attach. <br /> Conditionally Exzsrpt Small Quantity Treatment operations may not operate unitr under <br /> any other iter. <br /> Number of units and attached unit specific notifications for each tier reported. <br /> A. Conditionally Exempt-Small Quantity Treatment <br /> D. Permit by Rule <br /> B. xx Conditionally Exempt-Specified Wastestream <br /> E. Commercial Laundry <br /> C. Conditionally Authorized <br /> F. Variance (Section 25143) <br /> II- GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA 0 0 0 0 2 5 9 1 8 4 BOE NUMBER (if available) H AHQ3 L L 2 7 5 3 3 <br /> FACILITY NAME Dameron Hospital Assoti3t ' <br /> (DBA--Doing Buaineu As) <br /> PHYSICAL LOCATION 525 West Acacia Street ' <br /> CITY Stockton CA ZIP <br /> 95203 - 2484 <br /> COUNTY San Joaquin <br /> CONTACT PERSON Mark G. _Koenig PHONE NUMBER/ ZO p <br /> (Fox Na.) (tax Nem) ` 9 )—�'L-�r25�. <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME <br /> For DTSC Um OrJy <br /> STREET <br /> Rcgion <br /> CITY STATE _ ZIP <br /> COUNTRY <br /> CONTACT PERSON (oNy complete if ro USA) <br /> PHONE NUMBER( <br /> (Fim Name) (L,st Nemc) <br /> DTSC 1772 (1/95) _ <br /> Pa or t <br />