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0 0 <br />State of California - California Environmental Protection Agency Department of Toxic Substances Control - HWMP <br />P.O. Boz 806, Sacramento, CA 96612-0806 <br />PERMANENT STATE ID NUMBER APPLICATION <br />,rr� �, ,� =•a r,,,,, .„ ,n., rm,sue review we nneroy-ane metrucuons caremuy, <br />NEW NUMBER REQUESTS Check all that appy. (See Instruct/ons.) <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 other than those hazardous waste listed In 40 CFR 261.5 <br />subparts (c) and (d), per month, complete Form 8700-12 for an EPA (federal) ID number. <br />For existing ID number. C A L_ O _a _a 3 -L a 2- 3- L <br />❑ 2. 1 am updating the mailing address and/or contact Information only. <br />❑ 3. 1 am Inactivating this ID Number. <br />1 am reactivating this ID Number. Reason (please select one): A. ❑ Verification Questionnaire B. X Other <br />❑ 5. 1 am changing the business name only, no ownership change. <br />(See instructions.) <br />6. Site/Facility/Business Name (Include DBA): hAc, Ra+r01-Bum '�N' �.A_I rC�rUr1.6oXa (•n <br />7. Site Location: 2,t �-�i <br />Street <br />8. (a) Federal Employer ID NumberA ,_ „ - (b) Board of Equalization Fee Account <br />((b) Is only required from generators of gn <br />9. Mailing Address: <br />Q 5 I (See Instructions.) <br />� fn•�.1.ht�nhlT <br />greet <br />l.ilr,e.rt•+r,l�.r c,-f� 94s.s'f <br />OItY 3fate Zip <br />(See instructions.) <br />10, Site Contact Person: � 1{hdB1r �',l t1q. � <br />First erne Last N e <br />Contact Person Address: <br />street <br />1Lg&rn�llrp �� 9GSS1 <br />City State Zip <br />Contact Person Phone Number: od$ C ILI — }U o(� Fax Number: (?,IZ <br />A <br />rea e Phone Number Area Code Fax Number <br />Contact Person Business Email Address:Preferred Primary Communication: ❑ Mall Email <br />11. Legal Business Owner (not property owner): iiAKp vM 01T� n (See Instructions.) <br />Name <br />Owner Address: aS}o Ggts,.,o �asGn o��ultte G!F gyc'2-A <br />Street City State Zip <br />Owner Phone Number: (ans )Q IT — Oho C Fax Number: (4;S•1 <br />Area Code Phone Number Area Code Fax Number <br />12. Standard Industrial Classification (SIC) Code for the Site: <br />13. Certification: I certify under penalty of law that the Information on this document <br />belief to be, true, accurate and complete. <br />NAME (print) <br />tt,6 svjq <br />of my <br />TITLE 1kDr-6eEf&9- PHONE 9`.�S"'-4C'6-S}� x(i <br />