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State of California - California Environ l Protection Agency <br />Submit to: <br />Attn: Universal Waste Section <br />hannrfm nT of Tn or Ci ihctnnrac rnntrol <br />Hazardous Waste Management Program <br />1001 "1" Street, 11th Floor <br />P.O. Box 806 <br />Sacramento, California 95812-0806 <br />(916)323-9219 <br />Department of Toxic Substances Control <br />If you remove 'materials that require special handling' from a major appliance, after January 1, 2006 you will need <br />to provide evidence that you are a certified appliance recycler, pursuant to Health and Safety Code 25211 (AB <br />2277, 2004). <br />If you wish to operate as a certified appliance recycler you will need to submit this application to the Department of <br />Toxic Substances Control (DTSC), to obtain certification. <br />1.) Business name under which the recycler operates: St. Joseph's Medical Center <br />Facility address: 18nn North forma Street <br />(Not required) Stockton, CA. 95204 <br />Applicant name: John Staga <br />Phone number: (71719) 467-630B <br />2.) Business owner information: <br />Name: Catholic Healthcare West 2 ( D.B.A. St. Joseph's Medical Center) <br />Address: 1800 North California Street, Stockton, CA. 95204 <br />Phone: (209) 943-2000 <br />3.) Hazardous Waste generator identification number: (EPA ID #) CAD078796406 <br />(If required. If you need to obtain a California EPA ID # complete DTSC Form 1358.) <br />4.) Applicant has filed an application for a stormwater permit? YES i NO <br />Is the applicant required to obtain a stormwater permit? YES/ NO <br />5.) Applicant has filed a hazardous materials business plan? YES/ NO <br />Is the applicant required to file the plan? YES i NO <br />DTSC 1428 (12/2212005) 1 of 2 <br />