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-- <br />State of Californi -Califomia Environments mtection Agency Department of Toxic Substances Control - GISS <br />P.O. Box 806, Sacramento, CA 95812-0806 <br />eset Fo Print <br />CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br />Please type or neatly print in ink. Please review the line -by-line instructions carefully. <br />To check on the status of your request, go to www.hwts.dtsc.ca.aov and click on Reports <br />NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br />❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: A Generator []Transporter <br />Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. 0 Legal owner of business changed <br />If your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br />CHANGES TSTATUS OR INFORMATION FOR AN EXISTING ID NUMBER vv (See instructions.) <br />For existing ID number. C A 2 <br />❑ 2. 1 am updating the mailing address and/or contact information only. <br />❑ 3. 1 am inactivating this ID Number. <br />A( 4. 1 am reactivating this ID Number. <br />❑ 5. 1 am changing the business name only, no ownership change. <br />(See instructions.) <br />6. Site/Facility/Business Name (Include DBA): <br />7. Site Location: 2 <br />Street tC�L�'fi�s� ick <br />city State Zip County <br />8. (a) Federal Employer ID Number %' [ % (b) Board of Equalization Fee Account Number <br />((b) is only required from generators of greater than 5 tons per calendar year.) <br />9. Mailing Address: 2-2— 0 /,U/ I6. i . rho t <br />(See instructions.) <br />Street <br />—I <br />City State Zip <br />�y <br />up"? <br />p� r tG a-iro o,_ (See instructions.) <br />10. Site Contact Person: j� <br />First Name Last Name <br />Contact Person Address: 2 2 3 �i Guti () <br />Street f-� J^ r /�Jl <br />City State Zip <br />� j -1 <br />�UA i ` rC % 3 3 Fax Number: �(`Ga 7 % ,� �l `1' ri <br />Contact Person Phone Number: (_� (_� <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business Email Address: Preferred Primary Communication: flimail ❑ Email <br />11. Legal Business Owner (not property owner): <br />Owner Address: <br />Owner Phone Number. <br />>l <br />et - " City State Zi <br />(� L, u 5 Z� 3 Fax Number: (� <br />Area Code Phone Number Area Code Fax Number <br />(See instructions.) <br />12 Standard Industrial Classification (SIC) Code for the Site: L J _2_ je-L (4-ulgit Numoer) (Ouu nr�uu6uvnaj t <br />13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br />belief to be-twpe,,acc(jrateprld complete. <br />SIGNATURE Y'' <br />NAME (print) <br />TITLE i W Aj e,/ PHONE 2-� `"l �$ti',52 3-3 <br />S <br />v <br />