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SuPrint Form State of California-California Environmental on Agency - b -mit b y -Email- - O.Box 806,Sacramento CA 95812-0806 CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink Please review the line-by-line instructions carefully. To check on the status of your Leguest,go to www.hwtsAtsaca. ov and click on Re rts. NEW NUMBER REQUESTS Check all that apply. (See instructions.) ❑ 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, contact US EPA for a federal ID number. - CHANGES STATUS O INFORMTFOR O EXISTING I NUMER (S�7structions.) For existing ID ID number: C A L '� �- -a Gr El 2. lam updating the mailing address and/or contact information only. —F �/ O ❑ 3. 1 am inactivating this ID Number. IK 4. 1 am reactivating this ID Number. ❑ 5. 1 am changing the business name only,no ownership change. J 6. SifefFarility/t3usinesrs�Name(Include DB/A) q r t (See instructions.)': '/" Iy / r t tyt r !�, 1 7. Site Location: I l �n W r �S L treet _-5 < 6ck-fo/h l� ' R.Saos �Sdh oo �&ctill city 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;rear.) ?�� .i'� (See instructions.)( S A h �/��Q l/ 9. Mailing Address: p City State Zip �Ll_Q 10. Site Goofed Person: ll{Y� U\ (See instructions.) First Name Last Name Contact Person Address: R, 1 r) Street —szr City State Zip Contact Person Phone Number. Fax Number. (2,0 04 22.� Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: ��pp Preferred Primary Communication: ❑ Mail ❑ Email g ( property ) �O 4 I f1 j -r u (See instructions.) 11. Legal Business Owner notowner - Name //� nn Owner Address: / —G—G UJi l n vt (A/n , fOGK �OAI C-4 r �a Street City State Zip Owner Phone Number. (j 0 9) Fax Number. Q.6 9) Area Code Phone Number Area code Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: s (4-Digit Number) (See instructions.) 13. Certification: /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. SIGNATURE //��Kt�m nKa'�-�'P � DATE_7 1fY'C.C� NAME(print)�qyn K ra'1 Q xn TITLE mom.�_R r PHONE � r 9G/1"2 USC Form 1356(8108)