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ENVIRONMENTAL HEALTH PAGE 03/03 <br /> Slate of Cakfomia-California �- <br /> EnNronmerdal Proloction Agency <br /> Department of Toxic SvUslances Control-GIBS <br /> P,O.Be-808,Sacramento,CA 105812-01105 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neaty print In ink. please review me Ine-0yline instrlctioru earelully, <br /> To check an a status o/ our re nasi oto www wra. <br /> !'! NUMBER R,EpUE ere Checkall Ihat apply, v and click on Ra s. <br /> art <br /> I am applying for a new Permanent California ID number as a hazardous waste (See ina6uchons.) <br /> Reason for new number: A. ❑ Never had a number B - (Generator Transporter <br /> f/your business generates greater man too 1%Of pCRA hazardO Business nesse moved <br /> C. r�i1 Legal owner of business changed <br /> P rxl US EPA/oral ---.I.-number. <br /> CHANG TO ST S O IN RMA ON FOR AN <br /> For existing ID number. C A S I G ID NU BE <br /> _ _ _ (See <br /> 2. 1 am updatng the mailing address and/or contact irlformatlon only, <br /> 3. 1 am inactivating this ID Number. MAR _5 Q�Z <br /> ❑ 4. 1 am reactivating this ID Number <br /> 5, l am changing the business name only,no ownership change. 4 (C 4FESANJM fl(pN p N7y <br /> GENG �RVICEg <br /> 6 Site/Fatality/Business Name(Include DBA); (ijcsi 7"7J Mph! V (Sae lnsbuUfons.) <br /> 7. Sne Location. ?/ /V//rv'eft <br /> Sheet <br /> `-rcC/-..,cry <br /> CtyZip - Counlr <br /> e. (a)Federal Employer ID Number State - " <br /> --z� . Board of Equalization Fee Account Number <br /> ((bJ k onty required fiom ge wrafors o1 g eater men 5 tons per calendar year.) <br /> g Mailing Address11J!6, d ) <br /> (Sea In,Shudt7ns. <br /> C State <br /> Zip <br /> 10. She Contact Peraw.. _.!' -i-/ •�•;. , <br /> kishictions.) <br /> LN <br /> Contact Person Address: ac, <br /> SUeel .,rr.- <br /> . .�rae\/ <br /> City 3i <br /> Contact Person Phone Number, L( f''/ ) ..I�;IQ- !i.j; <br /> Area Code PltorK N„gebN Fax Number. (� <br /> Area Cafe Fax Neenber <br /> Contact Person Business Email Address: Lel'—54 u•r Cl yq�t,;,;, <br /> PrePorted Primary Comrnunica6on:QMail amen <br /> 11. Legal Business Owner(not prop"effe". G.i:Ct f L`e T Li ,c_:.� : (See inslnxcaons.) <br /> Owner Address: C.!= lifeline, <br /> Street C.;... J" rri �1D•'.r'i C.I-; QH. Y..-. <br /> Owner Phone Number; ( •u" •l1!S � sale aP <br /> AMC Phone Number Fax Nlxnber. ( Code Area Coda Fax tyatler <br /> 12. Standard IrdUstrial ClassifiCMion(SIC)Code!or the Site: <br /> (4'Di9d Number) (See instroc(fons.) <br /> 13. Certification. f cerhly underpenafly ollaw Thal mo rnformarion on this <br /> belief ro be, We,acculafa and compfefe, document was prepared to me best 0/my knowledge and <br /> SIGNATURE �e <br /> NAME(print) k02VG l ✓ N <br /> TITLE_p WN gr"e _ PHONE 911- <'//3 <br /> DTS Form 135&(6,M) <br />