Laserfiche WebLink
0 9 <br />State Of CallbMIN- CaHomla Enraorwrrrtal Praledim Agaegr Depanno t of Toric &fttwras CMW • GISS <br />® P.Q. Box 908. Savamenb, CA 858124)808 <br />CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br />Please typo or neatly Prom In tie Pleere review the line-by-ke wolnx*ne careMy. <br />To drex an the SfanM o/ your MPHOt, 90 t0 and lid[ an <br />NEW NUYBER REQUESTS (7iedt all and apply. (See insmxbarm) <br />1. 1 am applying for a new permanent California ID number as a hazardous waste: Q Generator OTransporter <br />on <br />Reaslor new muber A ❑ Newer had a number B. r] Business moved C. 1'j Legal owner of business dwrged <br />For existing ID number. -q A -L O O_, (, 3 X 2 1 L <br />0 2. 1 am updating the mailing address andior contact information only - <br />0 3. I am inaXhsking this ID Number <br />® 4. I am reacliwalng Ibis ID Number. <br />5. 1 am charging the business name only. no <br />8. SFad5lylBuainaas Marro (tnrAde Den): Y' <br />ital <br />7. Site Locatiorc I)E``i. PJe53GYn Lr AJ<- <br />9tiaM <br />& (a) Federal Employer 10 Number 27 - I067z` 8 `) (b) Board of Equalization Fee Account <br />9. Matting Address PO � OT IS -7-7 (See kul"9110118.) <br />- C—A h ttl NS 0100'7 <br />c1ty Sesr ap <br />�-" " ' f) {see suavuauona.l <br />10. Sits Contact s: Perm0I LRrIn <br />F' Name Last Harr <br />Contact Penton Adder 11, 6 L (3 2.5'ie.MLr R J L✓'� J �. <br />9ew1 <br />Manteca. ( Q533 -t <br />City State $ <br />Contact Person Phone Number. (300J (a -373 5 Far Nu ber, (93g1 so3-16 3 <br />Am Coda Phew eNrreer Awa Cods Fax Nun0W <br />Contactperson SwirassEmail Address' .i`rrtvV��r�?'lt.z�}U�asln,'tr7,ty, Preferred <br />1 (seer;nsVradars.) <br />11. Legal Business Owner(notprapany wear): i•ILCY�nI <br />0. Address: Po Gox 1577. West (aldvae-ll N; 0-100 <br />Sked CIV soft <br />OwrterPhoneNunber. (43 ) 0`-1`1-3"135 FMNWMW. Lan__) 50% 26 73 � <br />Area Cada Peer Baba Area Cada Fax Nianber <br />13. Ce 0catlon: l carffy older penally of lawdW do Ankh sYae on Nlia doasrsrnt was prepaed ta8s beat of my )vawkdge and <br />be WAD be, 4us, somata and conWbo <br />. - <br />SIGNATURE 7� DATE 1 i tl2n rP.1Q i n` <br />NAME(print) DaAme1 GacI1•ot� TIRE assi-. RcnraAwl Mn�r PHONE l3x -3187 <br />DTSC Fpm 135816x81 <br />