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Suite of Catircrnia-C&Uoreia FoT ri zsoev"rotectiou A1eary Check umber `r/ Dep"tweat or Toxic Subsuu,,e Coatrd 11q0 79 2 O O 8 Page I of ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM FACILITY SPECIFIC NOTIFICATION UFor Use by Hazardous Waste Generators Performing Treatment Initial Under Under Conditional Exemption and Conditional Authorization, 1:_3 and by Permit By Rule Facilities O Revised A Please refer to rhe attached Instructions before completing this form. You may notilyfor more than one permitting tier by using this notification form, DISC 1772. You must attach a separate unit specific not(cation form for each unit at this location. There arc different unit specific not f cation forms for each of the jour categories and an additional not(cation form for transportable treatment units rM's). You only have to submit forms for the tiers) 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 appropriare fee for each tier under which you are operating. (Please note that the fee is per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, You only owe $1,140, NOT timer$1,140. Ifyou 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 notification forms you must arrack. Cottdulonolly Ezempt Small Qttantttry Trearment operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier ,not per umt) A. Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) 5 100 B. Conditionally Exempt-SpfitdFoo(Form DTSC 1772B) S 100 � C. Conditionally Authorizen��cP Form DTSC 1772C) SI,140 D• Permit by Rule ��mI,F rm DTSC 1772D) $1,140 = �Total Number of Units a°J�� Total Fee Attached $ 100 GENERATOR IDENTiF7CATiEPA ID NUMBER CAD 0 4 1 B 4BOE NUMBER (if available) HAHQ3 6 0 2 7 5 3 3 NAME (Company or Facility) tDBA-Doing Business As) PHYSICAL LOCATION DAMERON HOSPITAL ASSOCIATION 525 WEST ACACIA STREET For DTSC U,e Only CITY STOCKTON CA ZiP 95203 - Region 'OUNTY SAN JOAQUIN CONTACT PERSON THObIAS BECK PHONE NUMBER( 209 )461 - 3176 (First Name) (LAM Name) ncr