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Pa;e 1 of 3 I i ONSITE HAZARDOUS�iwI E TREATMENT NOTIFICATION FORM ( FACILITY SPECIFICN��jj�jjFICATION For Use by Ha^$Gd& '�isteUn�tdYs Performing Treatment ❑ Initial U2 Under Conditional Exemption and Conditional Authorization. ❑ Revised and by Permit By Rule Facilities 0 y` Please refer to the attached Instructions before completing this form. You may nosh for more than one permitting tier by using this notication form, DTSC 1772. You must attach a separate unit speck notificationform for each unit at this location. There are different unit specific not ficadon jornu for each ofthefour categories and an additional norificationform for transportable treatment units r1'!U't). You only have to submit forms for the tier(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 pager at the top of each page'at the Page _ of_'. Put your EPA ID Number on each page. Please provide all of the information requesred; all fields must be completed except those that stare '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 appropriatefee for each tier under which you are operating. (Please note that rhe jet is per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorised, you only owe$1,140, NOTS timer 51,140. lfyou operate any Permit by Rule units and any units under Conditional Authorisation 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 w111 also be the number of unit speck notification forms you must attach. Conditionally Exenpr Small Quantify Treatment operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier A. ' Conditional) Exempt-Small toot per un,tr Y p Quantity Treatment (Form DTSC I772A) S 100 B. 1 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) S 100 C. Conditionally Authorized (Form DTSC 1772C) $1,140 D. Permit by Rule (Form DTSC 1772D) $1,140 1 Total Number of Units Total Fee Attached S 100.00 11. GENERATOR IDENTIFICATION EPA ID NUMBER CAL 0 0 0 0 6 3 1 1 5 BOE NUMBER (if available) H FHQ 3 8 0 0 1 9 7 0 NAME (Company or Facility) Delta Radiology Medical Group, Inc. (DBA—Doing Business Ar) PHYSICAL LOCATION 541 S. Ham Lane, Suite B For DTSC Use Oniy CIT' Trrli CA ZIP 95240 Region 'OUNTY San Joaquin CONTACT PERSON Orlin- Koehmstedt PHONE NUMBER( 209 ) 466 5027 (Fire Nsmc) (tau Nama) DTSC 1772 (1/93) Page I