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partment of Toxic Substances Control-GISS <br /> State of California-California Environmem10ction Agency ,p.Box 806,Sacramento,CA 95812-0806 <br /> Reset.Forme Print <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 our re uest, o to w.vw.hwts.dtsc.ca. ov and click on Re Reports. <br /> (See instructions.) <br /> NgA NUMBER REQUESTS Check all that apply. ` / <br /> 1. 1 am applying for anew permanent California ID number as a hazardous waste: (�(Generator Transporter <br /> Reason for new number: A. Never had a number B. El Business moved C. Legal owner of business changed <br /> if your business generates greater than 100 kg of RCRA hazardous waste per month, con act US EPA for a federal ID number. <br /> 7existing <br /> TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> ID number: C Aupdating the mailing address and/or contact information only. <br /> 3. I am inactivating this ID Number. <br /> 4. 1 am reactivating this ID Number. <br /> E] 5. 1 am changing the business name only, no ownership change. <br /> (See instructions.) <br /> 6. Site/Facility/Business Name(include DBA): SC k4�� S+zeJ <br /> 7. Site Location: ;2�Lj qU� <br /> 1Street'k4 <br /> � SQ� IM9u711. <br /> S-�-or k4on Zip County <br /> City Slate <br /> 8. (a)Federal Employer ID Number Sb- 03/8760 . Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> 17 tQ (See instructions.) <br /> 9. Mailing Address: �� .(�0X I �� I <br /> DOS <br /> 1�1DQHi r;ZOrnA Cgr <br /> ily State ZiP <br /> AtLdt- (See instructions.) <br /> 10. Site Contact Person: 4 <br /> First Name <br /> Last Name <br /> Contact Person Address: e .30I N9y //�' <br /> 5-Mc C/or <br /> City ''��""''uu '' r� r State Zip <br /> Contact Person Phone Number. 901 1 ���" 086Y Fax Number: (209)Area Code / Phone/N/umb/err Area Code Fax Number <br /> Contact Person Business Email Address:Chgsja.giD of �`S[��f�.Cdr Preferred Primary Communication:E]mail Email <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): A I Pgy4lkCIg'rti J9Qwv' 4 w-- <br /> Name � <br /> Owner Address: D 3oX �90y8 p6an,L Ai)z°nh g�OOS <br /> Street Gty "��'�Rate '/ zip �/ <br /> Owner Phone Number: Oo1 o?Sa - 7787 Fax Number: (6o2) 7y'f - 03 7 <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: I cerci u farpenalty of law the to information on this document was prepared to the best of my knowledge and <br /> belief to be, tru to and comple <br /> SIGNATOR /� /� J DAITE O� <br /> NAME(prnt) Cytase- _ �1a* TITLEs9f2�y 10 7.h1i )Z PHONE 209' 138' 08b8 <br /> DTSC Form 1358(6/08) <br />