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State of Ceforuio-Laliforois Fariror "as Protection Agency � -: ... . — <br /> =Umber "'. � s �� ®1 of Toa Ss6suocn CaovdMAR 3 1 13,�'s3 Page 1 Oflp <br /> i ENVIRONMENTAL HEALTH <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment <br /> U ® Initial <br /> Under Conditional Exemption and Conditional Authorization, 11 <br /> 3 and by Permit By Rule Facilities Revised <br /> t j Please refer to the attached Instructions before completing this form. You may notes far more than one permitting tier by using[his <br /> notification form, DTSC 1772. You must attach a separate unit spec f c not(cation farm for each unit at this location. There are <br /> different unit specific rtot feation forms for each of the jour categories and an additional notifrcation form for transportable treatment <br /> units (TTU's). You only have to submit forms 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; all fields must be <br /> completed except those that state 'if different' or 'if available'. Please type the information provided on [his form and anv <br /> attachments. . <br /> The notification will not be considered complete without payment of the appropriate 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 5 units but they are all Conditionally Authorized, <br /> you only owe$1,140, NOT times$1,140. Ir you operate any Permit by Rule units and any units under Conditional Authorization <br /> you owe$2,2&).) 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 ID Number on the check. Fill in the check number in the box above. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific not f cation forms you must attach. <br /> Conditionally Exempt Small Quantity Treatment operations may not operate units under any other tie,. <br /> Number of units and attached unit specific notifications Fee per Tier <br /> A not per u 'N Conditionally Exempt-Small Quantity Treatment (Form DTSC 1772A) 5 100 <br /> B. Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) 5 100 <br /> C. Conditionally Authorized (Form DTSC 1772C) $1,140 <br /> D. Permit by Rule (Form DTSC 1772D) 51,140 <br /> Total Number of Units Total Fee Attached $100.00 <br /> 11. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA L_2 12 2 0 3 3 3 8 _ BOE NUMBER (if available) H_HQ_ _ _ _ <br /> NAME (Company or Facility) STOCKTON RADIOLOGY MED GRP INC <br /> iDBA–Doing Business As) <br /> PHYSICAL LOCATION 1617 N- fAi TFORNTA SUITE 1A <br /> For DTSC Cx Oniy <br /> CiTY STOCKTON. CA ZIP 95204 <br /> Region <br /> OUNTY SAN JOAQUIN COUNTY <br /> CONTACT PERSON THOMAS THOMAS PHONE NUMBERp09 ) 948 -6063_ <br /> (First Nsme) (Lu Name) <br /> NOTIFICATION MADE BECAUSE OF ANTICIPATED PURCHASE <br /> DTSC 1772 (1/93) OF RECYCLING UNIT. Page I <br />