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State of California_California Ea iro=eoul Protection Agcy Department or Toot Suhrams Caeard <br /> 69643 r (? t r7 v Page I of 6 <br /> L69643 <br /> 9 2 0 0 0 0 6 <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment initial <br /> V Under Conditional Exemption and Conditional Authorization, ❑ Revised <br /> C a and by Permit By Rule Facilities <br /> Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this <br /> notification farm, DTSC 1772. You must attach a separate unit specific notification form for each unit at this location. There are <br /> different unit specific notif cation forms for each of the jour categories and an additional notifcation form for transportable treatment <br /> units (77T1's). You only have to submit forms for the her(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 this 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 TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> You only owe$1,140, NOTS rimer$1,140. If you operate any Permit by Rule units and any units under Conditional Authorilalion <br /> you owe $2,280.) 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 /> 1. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit specific notificationforms you must attach. <br /> Conditionally Exempt Small Quantity Treatment operations may not operate unius under any other tier. <br /> Number of units and attached unit specific notifications <br /> Fee per Tier <br /> A. Conditional) Exempt-small rnot per ,,no <br /> Y P Quantity Treatment (Form DTSC 1772A) $ lib <br /> B. 1 Conditionally Exempt-SpeciFi Waztestt;ea' (Form DTSC 1772B) S 100 <br /> C. <br /> Jcrcena�o <br /> Conditionally Authonzed <br /> re's `,(Form DTSC 177X) $1,140 <br /> D. - Permit by Rule (Form DTSC 1772D) 51.140 <br /> Mf1R 1 91993 -- ---- <br /> 1 Total Number of Units` <br /> a <br /> \ ;o:ansnf Total Fee Attached $ 100. <br /> �css: <br /> 1►• GENERATOR 1DENTiF1CAT101� 2,4 7p.ENt° <br /> EPA ID NUMBER CAS Q 0 0 -1 -92-7-j--.2 BOE NUMBER (if available) H GHQ_j _fi _Q 2 _I <br /> NAME (Company or Facility) LODI MEMORIAL HOSPITAL WEST <br /> (DBA—Doing Buamem As) <br /> PHYSICAL LOCATION 800 S. LOWER SACRAMENTO ROAD <br /> P.O. BOX 3004 <br /> CiTY For DTSC L; a Only <br /> LODI CA ZIP 95241 _ 1908 <br /> "OUNTY SAN JOAQUIN Region <br /> CONTACT PERSON DENNIS MARLOW <br /> PHONE NUMBER( 209) 368 _ 6654 <br /> (Fim Neme) (Lau Nemo) <br /> DTSC 1772 (1/93) page I <br />