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utue.r ....Page 1 of 3 <br /> r.. <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM <br /> FACILITY SPECIFIC NOTIFICATION <br /> For Use by Hazardous Waste Generators Performing Treatment B" Initial <br /> Under Conditional Exemption and Conditional Autborization, ❑ Revised <br /> + and by Permit By Rule Facilities <br /> a <br /> Please refer to the attached Instructions before completing this form. You may noth for more than one pfrmitting tier by using this <br /> notification form, D7SC 1772. You must attach a separate unit speck not fication form for each unit at this location. There are <br /> different unit speck not fication forme for each of the four categories and an additional nor fication form for transportable treatment <br /> units (17U's). You only have to submit forms for the tier(s) that cover your unit(s1. Discard or recycle the other unusedforms. <br /> Number each page of your completed not fication package and indicate the total number of pages at the top of each pagi 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 onv <br /> attachments. <br /> The norifica)ion will not be considered complete without payment of the appropriate fee for each tier under which you are operating. <br /> (Please note that thefee is per TIER not per UNIT. For example, if you operate S units but they are all Conditionally Authorized, <br /> you only owe 51,140, NOT S rimes $1,140. Ifyou operate any Permit by Rule units and any units under Conditional Authorisation <br /> you owe$2,280.) Checks should be made payable to the Department of Toxic Substances Control and be stapled to the top ofthis <br /> form. Please write your EPA ID Number on the check. Fill in the check number in the box above. <br /> I. NOTIFICATION CATEGORIES <br /> Indicate the number of units you operate in each tier. This will also be the number of unit speck notificationjorms you must attach. <br /> Conditionally Exempt Small Quantity Treatment operations may not operate unift under any other tier. <br /> Number of units and attached unit specific notifications Fee per Tier '. <br /> 'not per unu) <br /> A.' ._ Conditionally Exempt•Small,.Quartz• Treatment (Form DTSC 1772A) S 100 <br /> 1_ Conditionally Exempt$pdCfted Was,tytrpa (Form DTSC 1772B) <br /> $ 100 <br /> C. Conditionally Auolaii.w (Form DTSC 1772C) $1,140 <br /> D. a'vePermit by Rule ,vN2 (Form DTSC 1772D) $1,140 <br /> �' au es= aavams <br /> CEci V <br /> 1 Total Number of l its Total Fee Attached S 100.00 <br /> Agoura <br /> 11. GENERATOR IDENTIFICATION <br /> EPA ID NUMBER CA.L Q.Q_ 0 0 11- 1 1 6 BOE-NUMBER (if avat1able) H FHQ3• •8 0 0 1 9 7 0 <br /> NAME (Company or Facility) Delta Radiology Medical Group Inc <br /> (DBA—Doing Business As) <br /> PHYSICAL LOCATION <br /> 1121 W. Vine St. , Suite 15 <br /> CITY Loodi CA ZIP 95240 rRo�ri, <br /> DTSC c.e Only <br /> n ' <br /> 'OUNTY Gan .Tnacplin <br /> CONTACT PERSON Orlin Koehmstedt PHONE NUMBER( 209 ) 466 5027 <br /> (Fitt+ Name) (Lass Nsme) <br /> DTSC 1772 (1193) Pae 1 <br />