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State of California — California Environmental )vection Agency ..dartment of Toxic Substances Control - HWMP <br />P.O. Box 806, SacramentotQ� 6� 1 -0 <br />PERMANENT STATE ID NUMBER APPLICATION W 3 cu16 <br />Please type or neatly print in ink. Please review the line -by-line instructions carefully. <br />To check on the status of vour reauest, ao to www.hwts.dtsc.ca.00v and click on Reports. ' ii i i i r uP7hlAaC�erre r <br />NEW NUMBER REQUESTS Check all that apply. (See:iA <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 />CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) <br />For existing ID number: C A Q C) � 2' _ <br />❑ 2. 1 am updating the mailing address and/or contact information oTy. <br />❑ 3. 1 am inactivating this ID number. <br />p197I am reactivating this ID Number. <br />❑ 5. 1 am changing the business name only, no ownership change. <br />6. Site/Facility/Business Name (Include DBA): <br />7. Site Location: <br />8. (a) Federal Employer ID Number <br />(b) Board of Equalization Fee Account Number <br />g L9 LAI 1) W CE -S. T 1 to N CStreet <br />(see instructions.) <br />9. Mailing Address: <br />saolz�N C I+ Rszo <br />city State Zip <br />10. Site Contact Person: <br />Contact Person Address: <br />VL M1 <br />Contact Person Phone Number 2fl+ j L/30 (� Z. $y Fax Number: (7—o* q%G :79 A6 <br />Area Code�y �Ph�o�ne Number Area Code Fax Number <br />Contact Person Business Email Address: r+ y(„t,'Y ICA • 9 N Li Q <br />Preferred Primary Communication: ❑ Mail ❑ Email <br />11. Legal Business Owner (not property <br />Owner Address: <br />Owner Phone Number: (i9 J( %� p (t Z S � Fax Number: <br />Am ( ) <br />Aa Code Phone Number Area Code Fax Number <br />(See instructions.) <br />12. Standard Industrial Classification (SIC) Code for the Site: _ _ _ _ (4 -Digit Number) <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 />SIGNATURE <br />NAME (print) <br />DATE ;`fir-- 175' 1 <br />TITLE PHONE <br />