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'WANOO .m4f <br />State of California - California Environmental Protection Agency 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 -by-line instructions carefully. <br />To check on the status of your request, go to w wy.hwts.dtsc.ca.00v 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: A Generator ❑ Transporter <br />Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. )8( Legal owner of business changed <br />If your business generates greater than 100 kg of RCRA hazardous waste per month, call (415) 495-8895 fora federal ID number. <br />For existing ID number: C A T a Y = (I. a - g -2 <br />�1(2. lam updating the mailing address and/or contact information only. <br />❑ 3. .1 am inactivating this ID Number. <br />❑ 4. lam reactivating this ID Number. <br />❑ 5. lam changing the business name only, no ownership <br />6. Site/Facility/Business Name (Include DBA): /C (71 <br />7. Site Location: _ 'TLJCI <br />(a) Federal Employer ID Number (b) Board of Equalization Fee Account <br />((b) is only required from generators of qn <br />JAN $ 0 2010 <br />ENVIRONMENTAL HEALTH <br />PERMR/SERVICES <br />5 tons <br />(See instructions.) <br />::Foo <br />,e� n (See instructions.) <br />9. Mailing Address: �! L/� /7+'�.. <br />Street �' (ter li'/J -j 2, <br />City •CCS State Zip <br />10. Site Contact Person: Jai Ma ^ <br />Contact Person Address <br />GL Vi( <br />Street <br />5 % �oG4ruti% C A- g.iz 01 - <br />City State Zip <br />Contact Person Phone Number. ( 9 eel ) U6 L B2 Fax Number: ( <br />Area Lode Phone Number Area Code Fax Number <br />Contact Person Business Email Address: M r 1. O if' Ori, q(i�,f referred Primary Communication: o Mail ❑ Email <br />11. Legal Business Owner (not property owner): SSU 1Gi rntin U-, rJ . E -L Pot 1164% (See instructions.) <br />Name <br />Owner Address: 69?2 DisRer%r _t_ 1.14Y iTacAro/`i r QGiln <br />Owner Phone Number. (io9) Ll -Vz 9 n 2r Fax <br />12. Standard Industrial Classification (SIC) Code for the Site: <br />Certification: 1 certify under penalty of law that the information on this document was prepared to the best of my knowledge <br />belief to be, true, accurate and complete. <br />I "_ `" <br />NAME (print) / �eFt...nu� ar 901 - TITLE � �Cr PHONE=S 1O[.�Ifj.23` <br />