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State of California — California Environmental Protection Agency Department of Toxic Substances Control <br />P.O. Box 806 <br />Sacramento, CA 95812-0806 <br />California Hazardous Waste Permanent ID Number Application <br />Please review the instructions carefully and complete all items on the application. <br />1. Application for a permanent California ID number as a: Generator ❑ Transporter ❑ Both <br />2. This site is a: ❑ Large Quantity Generator `Small Quantity Generator <br />3. Change in previously issued ID number: <br />❑ Inactivate ❑ Reactivate <br />4. Site/Facility Name: <br />5. Site Location: <br />ID Number: <br />41/ /C .' <br />city I State zip County <br />6. Mailing Address: 112q <br />Street <br />�_A fN7CoP CA °1 S 33D <br />City State Zip <br />7. Site Contact Person: :TIM UZ,*Wr0A0 <br />First Name Last Name <br />Contact Person Address: <br />City <br />State <br />Contact Person Phone Number:6JZ�% % Fax Number: (7-0q) 658 -57;Z.7 - <br />Area <br />58 -57202 - <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business Email Ad( <br />Preferred Primary Communication: <br />8. LegalOwner: <br />fil <br />Owner Address:1i5C0 WK DOI° � Y 1 f-," <br />Street City State Zip <br />Owner Phone Number: t{( lJ )�` p,' 15S <br />Area Code Phone Number <br />9. Standard Industrial Classification (SIC) Code for the Site: -7 9 1 `'(4 -Digit Number) <br />DTSC 1358 04/02/2003 a , ^ 1/ 1*1 1 O,3 V <br />mt <br />