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i <br /> State of California-California Environmental Protection Agency Department of Toxic Substances Control -HVVMP <br /> P.O.Box 806,Sacramento,CA 95812-0806 <br /> PERMANENT STATE 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, o to www.hvvls.dtSc.ca.gQV and dick on Reports. <br /> NEW NUMBER REQUESTS Check all that appy. (See instructions.) j <br /> ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: R1 Generator ❑Transporter i <br /> Reason for new number: A. 91 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 6700-12 for an EPA(federal)ID number. — <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (Seetn �•'. <br /> For existing ID number: C A _ _ _ _ <br /> ❑ 2. 1 am updating the mailing address and/or contact info rmat(on only. MAR Q $ 2 �6 <br /> ❑ 3. 1 am inactivating this ID number. C��^t <br /> ❑ 4.1 am reactivating this ID Number. ENVf ROi�M <br /> ❑ 5. 1 am changing the business name only, no ownershipchange. gpnki- <br /> Q OOI 2fNC2 (Sen OYs) <br /> 6. Site/Facility/Business�Name(Include DBAL <br /> 7. Site Location: T b G •Te' e. <br /> Street Q Q Q ^ 3 h <br /> TT J 3 oq vtv� <br /> City <br /> +(b)Board of Equalization Fee Account Number Kg lok-090 2 <br /> (b)is only required from generators of greater than 5 tons per calendar ar. <br /> (Sae instructions.)9. Mailing Address: <br /> Street, r <br /> city State Zip �O <br /> ,^ OAVf (See instructions) <br /> Ir <br /> V <br /> 10. Site Contact Person: V � <br /> First Name PO 60y" 33�Last Name <br /> Confect Person Address: <br /> StreetZoon Cl-h <br /> 5 <br /> city [� State Zip a <br /> Contact Person Phone Number: ain 5°I-l'�JOO Fax Number. (201 23� O� <br /> Area Code Pho11ne Num�jr �1 Area Code Fax Number <br /> Contact Person Business Email Address: h(] VSA 1 k.Q,Y 72�' <br /> Preferred Prima Communication: 2 Maii Email <br /> 1, (See instructions.) <br /> 11. Legal Business Owner(not property owner): CIC WCA T�� <br /> R t ame Last Name <br /> Owner Address: 0 <br /> Stre_ <br /> city b <br /> C - ^ity r/ ` /s Sta <br /> Ct <br /> Owner Phone Number: a(j 5gq'830oate Fax NumbeZipr (7dq ��q- 35 0 <br /> Area Code Phone Number Area Code Fax Number <br /> ( <br /> (4-Digit Number) <br /> ._.---- (See lgstructions.) <br /> 13. Certification: I certify under ally// f law th If the i ormation on this document was prepared to the best of my knowledge and <br /> belief to be,true, accurst andc Pie <br /> SIGNATURE j� DATE <br /> NAME(print) Q.Yr Walker TITLE OWner PHONE (ZM)50t9-%W0 <br /> DTSC 1358(5129/15) <br />