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State of California—California Environmental Protection Agency Department of Toxic Substances Control GISS P.O.Box 806 Sacramento,CA 95812-0806 California Hazardous Waste Permanent ID Number Application Please review the line-by-line instructions carefully. New Number Reauests. Check all that apply. (See instructions.) 1. I 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 Changes to Status or Information. (See instructions) For IDnumber: C A ❑ 2. I am updating the mailing address and/or contact information only. ❑ 3. lain inactivating this ID Number. ❑ 4. 1 am reactivating this tD Number. ❑ 5. 1 am changing the business name. There has been no ownership change. 6. This site is a: X Generator of less than 1,000 kglmonth California-only waste (See instructions.) ❑ Generator of greater than 1,000 kg/month California-only waste ❑ Conditionally Exempt Small Quantity Generator of RCRA Waste 7. Site/Facility Name: �n I t rl / Irl d r }/ 8. Site Location: / r(e LV i I$ 0 n W d V Street s1 ti A . 4S. Os_ SQ i, (I/l a /h City —State Zip County —� ) -' / (See instructions.) 9. Mailing Address: J F G 0 I S c�h tiV� t/ Street �S4pr�l O n C A 9.fad c� City State Zip (See instructions.) 10. Site Contact Person: J o r i Q 119" L 0 L First Name Last Name r*� Contact Person Address: Street STar�� !eN City State Zip Contact Person Phone Number: Qo ) (4 7�j_o 5f Fax Number: Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: Preferred Primary Communication: A Mail ❑ Email .— / () / ' (See instructions). 11. Legal Business Owner((not pro/perry owner): J A C� 1 n is–Q N L a �1 p Owner Address: /SVo W 1 I S B h (�tJn y 5-1-or-00), t�r'I ! \5,a Q StreWf' City State Zip ^p� Owner Phone Number: I AreaCod Phone Number 12. Standard Industrial Classification(SIC)Code for the Site: %5 (4-Digit Number) (See Instructions.) DTSC Form 1358(9/04)