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Dec 07 04 04: 54p KHRIB$R 209-944 42.,93ECOM <br /> �i1b 255'-c(le3 DEC 7 2004 <br /> . Dep»#i�tt�NktlRttl�th6tl3'Ebhhol <br /> State of California—California EnvirotunentaPERMIT/SER1AO8'nx 106 <br /> l Protection Agency Sectamento CA 95812-0806 <br /> California Hazardous Waste Permanent ID Number Application <br /> Please review the instructions carefully and complete all items on the application. <br /> 1. Application for a permanent California ID number as a: Generator ❑ Transporter 7 Both <br /> 2. This site is a: 0 Large Quantity Generator Small Quantity Generator <br /> 3. Chan in previously issued ID number: ID Number:___ --------- <br /> Inactivate p Reactivate <br /> 4. Site/Facility Name: <br /> �av1 t to od ShJ <br /> �r Im�n <br /> 5. Site Location: Street L(iJ'�p� rgGt �u �t r1 <br /> si'l7UA-0n Zip County <br /> City State <br /> 1� c �r�,t'✓10 n� <br /> 6. Mailing Address: S etGk �. <br /> rJ � <br /> City -State Zip <br /> Z� � r2 <br /> 7. Site Contact Person: Last Name <br /> First Name <br /> Contact Person Address: StrwilCj d f L <br /> J 4 IC �n Zip <br /> City GA <br /> State <br /> _, Fax Number: (����— <br /> Contact Person Phone Number: Area Code Phone Number <br /> AreaCode Fax Number <br /> A - Email <br /> Contact Person ry Communication: <br /> ooe�E�ic t on�ess:C M it - <br /> preferred Primary <br /> �l ,°`. t <br /> 8. Legal Owner: <br /> Name <br /> 1 G 2?r n <br /> Owner Address: City State Zip <br /> Street "kl D <br /> Owner Phone Number: Area Code Phone Number <br /> (4-Digit Number) <br /> 9. Standard Industrial Classification(SIC)Code for the Site: — <br /> DTSC 1359 04102t2003 <br />