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1 tate of California-California Environmenla6ection Agency .partment of Toxic Substances Control-GISS <br /> eset Fo 0 P.O.Box 806,Sacramento,CA 95812-0806 <br /> 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 your request,go to www.hwts.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: Ej 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 /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER �ECEI 'L 'ctions.) <br /> For existing ID number: C A _ _ _ _ _ <br /> ❑ 2. lam updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. NOV 0 9 2010 <br /> ❑ 4. 1 am reactivating this ID Number. <br /> EM/IRONMENTAL HEALTH <br /> ❑ 5. 1 am changing the business name only, no ownership change. PERMIT/SERVICES <br /> 0 (See instructions.) <br /> 6. Site/Facility/BusinessUName(Include U 1)'C'Cde DBA): � 1)'C' `I � YYJ <br /> 7. Site Location: 1 t��' C YVIA6 Ya %A <br /> StrNet, O( 0 <br /> - tI_CJ � c, Yl�S2o. s OG(13to <br /> City <br /> b)Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year) <br /> 9. Mailing Address: /961 S t- (See instructions.) <br /> Street /� �7 �} <br /> ` J-/1C./Z•'%O L'xJ L•Gi %.S <br /> City State Zip <br /> 10. Site Contact Person: e✓yam r Z (See instructions.) <br /> First Nalne Last Name <br /> Contact Person Address: 6 1 • Ulu Uin j <br /> St S <br /> t <br /> �OC1cirJf�3 <br /> City State Zip <br /> Contact Person Phone Number. '),-,Cj Fax Number: (� <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: Preferred PrimaryCommunication: Mail Email <br /> (See instructions.)11. Legal Business Owner(not property owner): ;,>, ✓a hlei7lzr'n.'jc Z <br /> Name (, <br /> Owner Address: ✓ 5 TO/1-) <br /> Street ' <br /> ity State ZiD <br /> Owner Phone Number: (, 9 ) 2 - U `Y Fax Number: (� <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: a Z(4-Digit Number) (See instructions.) <br /> 13. Certification: /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 /> z , <br /> SIGNATURE % ;.r f.-�I YIyr.�'..,��.!-� DATE <br /> NAME(print)�1L /)- ��t'iitsi.2-yr LTITLE (JW�?N� =PHONE <br /> DTSC Form 1358(6/08) <br />