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State of California-Califomia Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> P.O.Box 808,Sacramento,CA 95812.0806 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or natty,print in ink. Please review the line-by-line instructions carefulty. <br /> To check on the status of your reguest, o to www,hWt$jt5C.r0,QQV and dick on Reports <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> 0 1. 1 am applying for a new permanent California ID number as a hazardous waste: Q Generator oTransporter <br /> Reason for new number: A. Never had a number B. [] Business moved C. Legal owner of business changed <br /> If your business generates greater then 1 t70 kg of RCRA hazaMous waste per month, contact US EPA for a federal ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number. C A L Q t7 C) 2 cl X 3 2 (o <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 /> 0 5. 1 am changing the business name only, no ownership change. <br /> -T n (See instructions.)6. SitefFacility/Business Name(include DBA): C�O1 ttVP� <br /> 7. Site Location: 2 PJ I4�Y�I[-1 Y1C� Ave— x e. (O <br /> Street <br /> City State Zip County <br /> 8.(a)Federal Employer ID Number Lt 25 2(oLl'b(b)Board of Equalization Fee Account Numberr�U <br /> ((b)is only required from generators of greater than 5 tons per calendarar.) <br /> @ (See Instructions.)9. Mailing Address: o�U 11 (�h��t ICiKLCI �'1r� e tp <br /> Street <br /> city state lap <br /> 10. Site Contact Person: _ <br /> 4�JC7� ,� (See instructions.) <br /> Find Name Last Name <br /> Contact Person Address: 1'01 1 t Mort �/lz✓ fir' <br /> Seems Li n d Gri �A G1523(p <br /> City seta Zip <br /> Contact Person Phone Number.. (20� ) 403 - 1 2(03 Fax Number. L?:�Ilj q�3 I-(oca8 <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: 1 (6Cl.l.•ID Prefered Primary Communication:M Mail ❑Email <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): b <br /> e Ca '9'5-Z3 1.0 <br /> Owner Address: IQS}I, l�l t-'lon.4c Ui�t�.. Dl� larlcte,n <br /> Zip <br /> Owner Phone Number(/-�'1 1 �1- 25(c/-� Fax Number. (�)���t 3i• g <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: _T S 3 L (4-Digit Number) (See instructions.) <br /> 13. Certification: I certify under penalty of law that the information on this document was prepared to the bast of my knowledge and <br /> berefro be, <br /> SIGNATURE --,-� _ DATE 3, aOl 0 <br /> NAME(print) TITLE (DWnC'X PHONE <br /> DTSC Form 1358(8/08) <br />