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State of California—Califomia Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> P.O.Box 806,Sacramento,CA 95812-0806 <br /> 3" <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.dt c ca.gov 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 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br /> EO <br /> O ST MATION FOR AN 1 TIN D N BER (See instructions.) <br /> D number. C A O � � 2 O 5 4,3 <br /> pdating the mailing address and/or contact information only. <br /> nactivating this ID Number. <br /> activating this ID Number. <br /> changing the business name only,no ownership change. <br /> 11, 11111, 11�. 1, (See instructions.) <br /> 6. Site/Facility/Business Name(Include/DBA): j <br /> 7. Site Location: � S 1'f rJ-1 SO y 37' <br /> rll � ^ <br /> or c ✓ Cot 9S'2o3 SoN-1�,u,{v <br /> City State Zip County <br /> 8.(a)Federal Employer ID Number <br /> <br /> is onty required from generators of greater than 5 tons per calendar year.) <br /> (See instructions) <br /> 9. Mailing Address: �i�l S G"(Q>"rc Sr�.J �4 <br /> Ca <br /> CatState Zip <br /> V I (See instructions.) <br /> rm�e <br /> 10. Site Contact Person: last Name <br /> FI me <br /> Contact Person Address: 6'41 S rT ottn S- eJ S`v <br /> S���-yC. X03 <br /> City State Zip <br /> Contact Person Phone Number: 02IJ y�2"-3�6 Fax Number: Area Code 9gFax Number0Z7 <br /> Area Code_/�'I Phone Numb1er 1 / �y <br /> Contact Person Business Email Address: i'N wr�"�-"""""S.(�Oh prefened Primary Communication: Mall J�(I Emall <br /> ($BB insWctions.) <br /> 11. Legal Business Owner(not property owner): ve— <br /> f{ame 9.`��ZOb <br /> Owner Address: Street <br /> /�!R V/I` , n tate <br /> city S <br /> (7� 942-2( <br /> Owner Phone Number: QQC ) Phone <br /> Num(- Fax Number. Area Cade Fax Number <br /> Area Code Phone Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: _ _ _ _ (4-Digit Number) (See instructions.) <br /> 13. Certification: I certify under penglity of few that the information on this document was prepared to the best Eknowledge, dbelief to be,true, urate an omplefe. <br /> SIGNATURE ATENAME(print) TITLE/5.,�, PHONE <br /> OTSC Form 1358(6108) <br />