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FROM FA`; NO. : 12093690153 Sep. 25 2000 01:30PM P3 <br /> 09/25/2008 THU 12: 11 PAR 2094__3433 SJC LHP 16003/003 <br /> State of GaUfomla—California Environmental Protection Axlency <br /> F)e artmont of Toxic,Substances Control-GISS <br /> P.Q.Box 800,Sacremanto,CA 9581$-0806 <br /> R` F Print <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or noatly print in Ink. Please review the ling-by-lino instructions carefully, <br /> To shack on the status oflour request. oto www.ltwl•°yb(„�,�yd„c.ca:�4Y RISA click On Reports, <br /> �NUMi3ER ( QUESTS Check alt that apply. (Sec instructions.) <br /> 1 I am applying for a now permanent California ID number as a hazardous waste: Generator (]Transporter <br /> IPA Reason for new number: A. [�Never had a numhwr R E] 1`1119 1A4s moved C• C]Legal owner of business changed <br /> g....___ es E.a. .._ ...._ g _... _...waste p _...a federal lU number, <br /> If our business-enerates renter than 900 k of RCF2/1 hazardous waste er month,contact US EPA for <br /> C 7 U3.. PO TIbN FOR AN 5T ID NUM.E (Soe instructions.) <br /> For existing ID number. ---- <br /> La 2. 1 am updating the mailing address and/or contact information only. <br /> Ll 3. 1 am inactivating this ID Number, <br /> Q 4. 1 am reactivating this ID Number. <br /> (] 5. I am changing the business name only,no ownership change. <br /> _ - (See irtstructrvrrs.) <br /> 6. Slto/Faciii <br /> ty/Business Name(Include 05A): r <br /> 7. Site Location: — <br /> Slroe , <br /> ` N. C <br /> city <br /> <br /> )is only required from generators of greater than 5 tons per calondar year..) _ <br /> (See instructions.) <br /> 9. Mailing Address; ) c, l— - <br /> Street 7_j <br /> Cit <br /> State ....,...... _ 7.ip _ <br /> 10. Site Contact Person: <br /> First Name Ld6t Nam <br /> Contsct Pet�on Address: <br /> Street <br /> tip <br /> city — State l <br /> Contact Person Phone Number (�( ���) �� .Z '7 ,'ZL Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: �, _b l L•j`�"�����"�M preferred Pr msry Cnmmunicallon;[]Mall ai>� <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): ... <br /> Owner <br /> Narna <br /> Owner Address: �? �)yT. <br /> Street City Stat6- 7_iu <br /> Owner Phone Number: � 2 P) `� 1 7 C3 Fax Number ( rx-L <br /> ( "b") ) Area Cod© Fax Number <br /> Area Code Phone Number -- •— <br /> 512.�Stn7dard Industrial Classification(SIC)Coda for the Site: - _ (4 Digit Numher) (See Instructions.) <br /> 13^ Certification: t certifyMunderPty of taw that the information on this document was prepared to the best of my knowledge andbellef to be,true,accmplete. <br /> er <br /> �- DATE <:SIGNATUREr <br /> NAME(print) �a1_ PHONIa_`t <br /> ::. <br /> oTSc Form 13158(6106) <br />