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06/18/14 01:05PH HP LASERJET FAX p.03 State of California-California Erwironmental iedion Agency ortment of Toxic Substances Control-GISS P.O.Box 806,Sacramento,CA 95812-0806 CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly prim in ink. Please review the line-by-fine instructions carefully. To check on the status of your request,go to www. v and dick on Re NEW NUMBER REQUESTS Check all that apply. (See instmctions.) ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste per month, call(415)495-8895 for a federal 1D number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER t For existing ID number: C A Z— D y V C) S _2 4} ❑ 2. 1 am updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID Number. JUN 18 2014 1,S�4. 1 am reactivating this ID Number. 0 5. 1 am changing the business name only,no ownership change. ENVIRONMENTAL HEALTH (see instructions.) 6. Site/Facility/Business Name(Incl ude DBA):-:bK-5 INV =5711 IJ 15 (TtC DRF1 L 'l-'sT LA&IT GtEyRu to 7. Site Location: street pity State zip County 8.(a)Federal Employer ID Number (b)Board of Equalization Fee Account Number ((b)is only required from generators of greater than 5 tons per calendar year.) (See instructions.) 9. Mailing Address: 9'��6 '7 ��-/L % `-�1 Sir", pity State K 10. Site Contact Person: c�ACC'�� 1 (See instructions.) ' First Nam Last Name Contact Person Address: i 1/k7p t }ejjr' 2 S I -'-1 Street. /j K " 7 5�/L city State Zip Contact Person Phone Number: r` 4 S Fax Number (,L2) ' L C 9 Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: S//,/G/ ..'>s1 icc c - Preferred primary Communication: o Mail 'Email (See instructions.) 11. Legal Business owner(not property owner): -b' S Nemec 9S2 z/� Owner Address: / Clty State ZrP Street — Owner Phone Number �� ..2l�- � Fax Number: L� Areas C Phone umber Area Gode Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: •-� �� (4-Digit Number) (See instructions.) 13. Certification: l certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true,accurate and complete. _ l SIGNATURE � � /�� , NAME(print) xnh�4�^ -S�� TITLE Q PHONEz�7?d� c-VZ1 DTSC Form 1358(10112)