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• 0 <br /> 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 www.hwts.dtsc.ca. ov and click on Reports. <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 ❑Transporter <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 than 900 kg of RCRA hazardous waste per month, call(495)495-8895 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_ C _ 0 _ S— 5 <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. <br /> 'A4. 1 am reactivating this ID Number. <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> a ./� MA.-di-AC <br /> � <br /> 6. Site/Facility/Business Name(Include DBA): �1 7� 'v 1(� i /�C (See instructions.) <br /> 7. Site Location: l I '?, ell>_ <br /> Street <br /> ( <br /> City State � Zip County <br /> 8. (a) Federal Employer ID Number (b) Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> Q' (See instructions.) <br /> 9. Mailing Address: o �-,�-� �4Y1, <br /> Street <br /> City State Zip <br /> 10. Site Contact Person: t (See instructions.) <br /> First Name Last Name 1,,^•—� <br /> Contact Person Address: I I �'(��Q%rV l0►'�/1 <br /> Street `� - r-A <br /> City State Zip <br /> �7 <br /> Contact Person Phone Number: 7� ( 1 1 Fax Number: (� <br /> Area dode Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: Preferred Primary Communication: ❑ Mail ❑ Email <br /> 11. Legal Business Owner(not property owner): (See instructions.)�-�, <br /> Owner Address: (/ ) R��� C �[ C'2 <br /> Streetty City State Zip <br /> Owner Phone Number: L '�`� Z � 3 Fax Number: (� <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: .� (4-Digit Number) (See instructions.) <br /> 13. Certification: /certify under penalty of w that the information on this document was prepared to the best of my knowledge and <br /> belief to be, true, a urat We. / <br /> ;� <br /> SIGNATURE DATE <br /> NAME(print) cL� �iL —TITLEOL0 01<V PHONE"—% <br /> DTSC Form 1358(10/12) <br />