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State of California — California Environmental Protection Agency <br />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-bWine instructions caretulty. <br />To check on the status of your request go to www.hvxs.dtsc.ca.00v and dick on ReD&ts <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, call (415) 495-8895 for a federal ID number. <br />For existing ID number: C A <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 />❑ 5. 1 am changing the business name only, no <br />6. Site/Facility/Business Name (include DBA): <br />7. Site Location: <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 greaterthan 5 tons percalendar. year) <br />( <br />9. Mailing Address: See instructions,) <br />Street <br />City Stale Zip <br />10. Site Contact Person: (See instructions) <br />First Name Last Name <br />Contact Person Address: <br />Street <br />City State Zip <br />AP`? 2 `' <br />Contact Person Phone Number: Fax Number: ( <br />Area Code Phone Number Area Code Fa"mbar <br />Contact Person Business Email Address: Preferred Primary Communition: ❑ Mall ❑ Email <br />11. Legal Business Owner (not progeny owner): (See instructions.) <br />Name <br />Owner Address: <br />Street City State Zip <br />Owner Phone Number: ( ) Fax Number. (_) <br />Area Code Phone Number Area Code Fax Number <br />12. Standard Industrial Classification (SIC) Code for the Site: <br />13. Certification: 1 certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br />belief to be, true, accurate and complete. <br />SIGNATURE DATE <br />NAME (print) TITLE PHONE <br />