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State of California-California Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> P.O.Box 806,Sacramento,CA 95812-0806 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly print In ink, Please review the line-by-line instructions carefully. <br /> To Check on the status of your request.go to w c.ca. ov and click on Re ons. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator DTransporter <br /> Reason for new number: A. D Never had a number B, ❑ Business moved C. ❑ Legal owner of business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste per month,contact US EPA for a federal ID number, <br /> CHANGES TO STATUS ORI FORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number; C A L_ - 0 Q a�-f -CL Q <br /> 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. <br /> ❑ 4. 1 am reactivating this ID Number. <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> ,� <br /> �n (See instructions.) <br /> 6. Site/Facility/Business Name(include DBA): AV'�o ka� I� I' �L pro �� <br /> 7. Site Location; <br /> Street <br /> "-rro C <br /> Cit � <br /> Board of Equalization Fee Account Number 41 -)0(0 5"'/. <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> 9, Mailing Address: <br /> Z 8'�0 Ay-� (See instructions.) <br /> Street U u <br /> City Zip <br /> 10. Site Contact Person: � -� 1 t�Iy C �Y O <br /> (See instructions.) <br /> First Name ( Last Name <br /> Contact Person Address; 2- �3 c) Q V ` O ���7`� -�4 r3 Q <br /> st` rc�e.y CC� G 53 Oy <br /> City 11 State Zip <br /> Contact Person Phone Number: (Zvc) 8� d []5._ i I I Fax Number; ( �) � S 1 - 9 '� 7 <br /> Area Code Phone Number Area Code Fax Number <br /> i A r7. ice. ( <br /> Contact Person Business Email Address: A�1 kie h n 4nov o Preferred Primary Communication:Wmall ❑Email <br /> fZW 1 � / tJ c-�,Y c) (See instructions.) <br /> 11. Legal Business Owner(not property owner): AmA !,.rr <br /> Owner Address: ? �3 `s�c� Nle L a Z, �� Ir✓Zc C- C. <br /> ty S <br /> Owner Phone Numbert (C-°�g� !f Fax I umber; (Z'Oft)tatt?� 3c�-RA -7 !F <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: 5 8 (4-Digit Number) (See instructions.) <br /> 13. Certification: l cartify u er penalty of law at a information on this document was prepared to the best of my knowledge and <br /> belief to be, true, o and complete. G� <br /> DATE I �� <br /> SIGNATURE O <br /> NAME(print) ��i Vy �-V C�� TITLES �'� PHONE <br /> DTSC Form 1358(6/08) <br /> T /T 'EDxa 5L8S6ES60Z SU010s NHVE01nx ria OC : CO TTOZ'8Z 'das <br />