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• <br /> State of California—California Environmental Protection Agency Department of Toxic Substances Control-GI SS <br /> �;rxrr P.O.Box 806,Sacramento,CA 95812-0806 <br /> NKRI <br /> rl <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 mvw.hwAs.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: Q Generator [3Transporter <br /> Reason for new number. A. 0 Never had a number B. [] Business moved C. Q Legal owner of business changed <br /> If your business generates greater than 100 kg ofRCRA hazardous waste per month, contact US EPA for a federal 10 number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN.EXISTING ID NUMBER (See instructions.) <br /> For existing ID number. C A _Q © .Q <br /> n 2. 1 am updating the mailing address and/or contact information only. <br /> 0 3. 1 am inactivating this 10 Number. <br /> 4. 1 am reactivating this ID Number. <br /> 5. 1 am changing the business name only, no ownership change. <br /> (See instructions) <br /> p <br /> 6. SitelFadlity/Business Name(Include DBA): L6Y,5X (°DNSTCuC7/n.� rs4YEPi.4ZS PAGE/ LLC <br /> 7. Site Location: 3 SO S6rV7.Y TR"fC r/ R&J-L fUll4b <br /> `Street <br /> 9376 59.E .a'ewQu.,z <br /> CityState 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 /> (See instructions) <br /> 9. Mailing Address: P�,,,�SC �97 <br /> Street <br /> Pt EA 502,17'oa (f4 9ys66 <br /> ity Slate Zip <br /> PLfSEZ% A�DErJ (See instructions) <br /> 10. Site.Contact Person: .yGrYS�`.,./ <br /> First Name <br /> > - O Last Name <br /> Contact Person Address: Po ,9'oK 6/7 ��yr/ Si�1w,LEY g[XIdEUq,?JJ <br /> y <br /> . city. State - ZIP <br /> Contact Person Phone Number: (7Z5) �929-,ZJ6/ Fax Number.-(7 Wr-2—.SJ 7Z <br /> Area Code . Phone Number . . Area Code Fax Number - <br /> ,�D$FRTA.ALDFN.NrVsd✓. <br /> Contact Person Business Email Address:—& CDM PreferreQPdmaryCommunication:ElMail Email - <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): CLc��X• <br /> Name <br /> Owner Address: � '70 <br /> Street City tate <br /> 2io <br /> Owner Phone Number. /G 9f'/ �f1r� Fax Number.`( <br /> AreaCode - Phone Number Area Code -Fax Number <br /> 12. Standard Industrial Classification (SIC)Code for the Site: L (4-Digit Number) (See instructions.) <br /> 13. Certification: ca##ttwxkrjoena1ty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be,true, cc rate I <br /> SIGNATURE � �� — DATE p/28%O <br /> NAME(print) K✓JR6,e/ t7`.C�En1al/tYSE.0 TITLE �Y/.PDw`+t�✓TIiG PHONE /.2S, �W- !� <br /> DTSC Form 1358(6108) <br />