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STATE OF CALIFORNIA CALIFOF INTEGRATED WASTE MANAGEMENT BOARD _1ISEU.OIL COLLECTION CENTER CL-.. iIFICATION APPLICATION CIWMB 29 (Rev. 17103) INSTRUCTIONS Print in ink or type. Submit a separate form for each location. Use N/A to indicate any items that are not applicable. 1. APPLICATION TYPE (Check One) ® Initial Application ❑ Recertification Application CIWMB Identification Number (To be completed by CIWMB 4 for initial certification) II. COLLECTION CENTER INFORMATION Oil Collection Center Name (Name of business as seen from street) Lathrop -Manteca Fire District, Station # 31 Street Address (location of oil collection center) City State Zip 800 E. "J" Street Lathrop Calif. 95330 Mailing Address (if different than street address) City State Zip 800 E. "J" Street Lathrop Calif. 95330 Contact Person's Name Contact Person's Phone Number Chester G. Smith, Division Chief, Operations Divison (209)858-2331 ext 385 County where Oil Collection Center is located Contact Person's Fax Number San Joaquin (209 858-1180) Hazardous Waste Generator (EPA) identification Number Total used oil storage capacity (in gallons) Federal Taxpayer Identification Number (Employer ID# or SSAN) 200 gallons Description of physical location of collection center, including nearest cross streets: Fire Station, 800 E. "J" Street w/cross of Ruby Ct. Lathrop, Ca. 95330 III. OPERATOR INFORMATION Operators Name Lathrop -Manteca Fire District Operators Mailing Address City State Zip 800 E. "J" Street Lathrop Calif 95330 Contact Person's Name Contact Person's Phone Number James Monty, Fire Chief (209)858-2331 EXT 384 Federal Taxpayer Identification Number (Employer ID# or SSAN) Contact Person's Fax Number (209)85&1180 Do you, the center operator, own or operate a used oil hauler business? ❑ YES ® NO OYES ®NO Do you, the center operator, own or operate a used oil recycling refinery? ORGANIZATION TYPE (Check One) A- For Profit: ❑ individual (Attach copy of fictitious business name statement or business license) ❑ Partnership (Attach a copy of current partnership agreement) ❑ Corporation (Write below the exact corporate name and number as filed with the ❑ Husband and Wife co -ownership (Supply both spouse's names) California Secretary of State) B. Non Attach copy of a letter from the Federal Internal Revenue Service or the State of California Franchise Tax Board confirming tax exempt status. Non- Proft: profit corporations may provide letter confirming tax exempt status or may write below the exact corporate name and number as filed with the California Secretary of State. [] Corporation name and number: ❑ C'nurch ❑School ❑ Youth Group ❑ Senior Citizen Group ❑ Other (Explain) c. Z Local Government Agency (Attach a copy of authorizing letter or resolution from the governing body) D. ❑ Other (Public School District, etc — please describe.)