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State of California-California Eo irvnmmt= "MiKtioo Agency Department of Tour Subwreea Control ec um r 'i Page I of 21 69642 ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION FORM RECj® FACILITY SPECIFIC NOTIFICATION S a P r ) else by Hazardous Waste Generators Performing Treatment I X Initial U MAR 2 � 3 Under Conditional Exemption and Conditional Authorization, Cl Revised n and by Permit By Rule Facilities o H ENVIRONMUTAL ViEN-Tw Please refer IPKRn �t6k&lUkons before completing this form. You may noir fyfor more than onerm peitting tier by using this I notification form, DISC 1772, You must attach a separate unit specific norication form for each unit at this location. There are different unit specific notOcarion forms for each of the jour categories and an additional notification form for transportable treatment units (77V 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 nor fication 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 appropriate fee for each tier under which you are operating. (Please note that rhe fee is per 77ER not per UNIT. For example, if you operate 5 units but they are all Conditionally Authorized, You only owe$1,140, NOTS rimes 51,14o. If you 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 Toric 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 notificationforms you must attach. Canditiarudly Ernripf Small Quantity, Treatment operations may not operate units under any other tier. Number of units and attached unit specific notifications Fee per Tier A, — Conditionally per un,p Conditionally Exempt-Small Quantity Treatment (Form DTSC I772A) S 100 B• 6 Conditionally Exempt-Specified Wastestream (Form DTSC 1772B) S 100 C. Conditionally Authonzed (Form DTSC 1772C) $1,140 D. _ — Permit by Rule (Form DTSC 1772D) SI 140 6 Total Number of Units Total Fee Attached S 100. 11 GENERATOR IDENTIFICATION EPA ID NUMBER CA L 0 0 0 0 4 3 0 7_8 BOE NUMBER (if available) HIS HQ 3 6 0 2 1 5 8 1 NAME (Company or Facility) LODI MEMORIAL HOSPITAL (DBA--Doma Busmen As) PHYSICAL LOCATION 975 S. FAIRMONT AVENUE P.O. BOX 3004 For DTSC U,e Only CITY LODI CA ZIP 95241 - 1908 Region 'OUNTY SAN JOA UIN CONTACT PERSON DENNIS MARLOW PHONENUMBER( 209 ) 368- 6654 (Fire Name) (Law Name) —a. DTSC 1772 (1/93) Page I