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o�w.uinuuc,wrotr�ouiagency Departmentof Toxic Substances Control-GISS <br /> ��t.Fdri4 Print -� P.O.Bax 806,Sacramento,CA 95812-0806 <br /> CALIFORNIA 11LRDOUS WASTE PERMANENT I UMBER 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.gov 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: 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 1D number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number: C A Q B <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> 1 am inactivating this ID Number. <br /> I am reactivating this ID Number. C Fl L Q Q 0© 1 6�S�'� ��tS � LS a ITSL <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> (See instructions.) <br /> 6. Site/Facility/Business Name(include DBA): C q-- S �'✓1 e ��{ � ,�, <br /> 7. Site Location: '97-56 e p)c_t F(c <br /> Street <br /> City State Zip County <br /> 8. (a)Federal Employer ID Number ��' 0 3f 6211( Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> 5 7 56 PA See instructions. <br /> 9. Mailing Address: C-�Ft G /.�+♦/� J ( ) <br /> Street <br /> S TO G(<T©^j c— A 9 S 2 07 <br /> city state zip <br /> 10. Site Contact Person: C lei V L C-9 PA 7L L, (See instructions.) <br /> First Name Last Name <br /> Contact Person Address: � 50 Q R-ib G C rail TC- t <br /> Street <br /> .s rock ro A/ C/1 9s z y <br /> City State Zip <br /> Contact Person Phone Number. C2,05) 609 w�4 Fax Number c 295)__47 9 <br /> Area Code Phone Number Ce-f f Area Code Fax Number <br /> Contact Person Business Email Address: 2_U 5 4 ­--0/6,1—preferred Primary Communication ail []Email <br /> 11. Legal Business Owner(not property owner): -r-6 0',/e , <br /> (See instructions.) <br /> Name <br /> Owner Address: <br /> Street City State Zip <br /> Owner Phone Number. U Fax Number: ( <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: ( 2— (4-Digit Number) (See instructions.) <br /> 13. Certification: t 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 /> SIGNATURE PATE /-Z ll/[l c' <br /> r <br /> NAME(print) P AT L L-. C N R A L6 S TITLE PHONE(zrJ SI'f 7 7 f32-/( <br /> (zo5� 6 0 9 - it 54 <br /> OTSC Form 1358(6/08) <br />