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Slale.of California-California Environmental Protection Agency Department of Toxic Substances Control-ISISS Reset Form P.O.Box 806,Sacramento,CA 95812-0808 Print CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line-by-line instructions carefully. To check on the status of your request, o to vrww.hwts.dtsc.ca. ov and Uick on R orfs. NEW NUMBER REQUESTS Check all[hat apply. (see instruct' ns.) ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter Reason for new number A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed U your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) For existing ID number. C A L- Q Q 0- 0-- _L Q S LA ❑ 2. 1 am updating the mailing address andlor contact information only. ❑ 3. 1 am inactivating this ID Number. 4. 1 am reactivating this ID Number. ❑ 5. 1 am changing the business name only, no ownership change- 6.6. Site/Facility/8usiness Name(Include DBA): /�/A&Te M 77RiF, (See instructions) 7. Site Location: it /W/. J'4Q/,$pif Street C4 MAsy7YC.4 c AAJ 9A �/r✓ City � Board of Equalization Fee Account Number ((b)is only rihquired from generators of greater than 5 ions per calendar yea!l 9. Mailing Address: C20/ . (See instructions) Street mar,✓Ttca 95336 city State Zip 10. Site Conrad Person /0 � /1��4 (See instructions.) : 19A2/G, p First Name ` Last Name Contact Person Address: 0491 E�/Sr7�✓ %Y street C4 A 3 city State zip q Contact Person Phone Number: (� 12,337%F55� Fax Number: (� 1 oW 3g^ 77 ZU Area Code Phone Numbers ` - //� .rArea Code Fax Number Contact Person Business Email Address:/hTfn✓liJ'/ (�1107MA)r eferFad Primary Communication: []Mail ❑Email gfLER '/� 11. Legal Business Owner(not property owner): rf ,(F ANOT (SeeLWructfons.)�" Owner Address: 74Y w �t7lSa� I*At/TCCsf �� 36 StrqL City stat Zip Owner Phone Number:(!1'S 1 239'.35 0 Fax Number: (209) b9- 77 Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: 7 $ 3 (4-Digit Number) (see insVuctkrns.) 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, urate an mplete. SIGNATU �� .RE /I ��ri�r7F1 DATE /d NAME (print) �L)-T �y/�/�+c-air✓ TITLE /)/I1.41�f.IL. PHONE �i3 '„3� DISC Form 1358(6/08) £'d 8ZLL-6£7,-60Z )PUBS UBA 58J0 864OL OL 170 ADN