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FROM <br />FAX NO. :12093690153 Tul. 10 2008 11:54AM P2 <br />JUL-09-2008 WED 12:03 PM ENUIRONMRNTAL MGMT DEPT FAX NO, 916-876 8513 P. 08106 <br />state of Cattrornla -- California Fnvironmentnl Protectlor Aganay <br />' <br />P,O. »ox 8170, Bacrsmento, CA 98812-0808 lb-)ss�-Z47Q3 <br />CALIFORNIA HAZARD DUS WASTE P ANETiIT7b'NUMBER APPLICATION <br />Please type or neatly print in ink. Please review the l(ne-by-line instructions oorefully, <br />o check on the status of your roquplt, go to www.hwta,dtscxa.go-v_ and oiick on Reports. <br />NEW NUMjEB RtaQUIESTS Check all that apply. (See Instructions.) <br />L1 1. I am applying for a new permanent California ID numkwr as a hazardous waste: ❑ Generator ❑ Transporter <br />Reason for new number; A, ❑ Never had a number B, ❑ Business moved C. ❑ Legal owner of business changed <br />If your business gensretes granter than 100 kg of RERA har�enlous waste per month, contact US EPA for a federal ID number - <br />For existing ID number. Q A C --P <br />M 2. 1 am updating the mailing address and/or contact Information only - <br />r] 3. 1 am inactivating this ID Number. <br />V4. I am reactivating this IA Number, <br />Q 5, 1 am changing the business name only, no ownership change. <br />(See Instructions,) <br />(See instructions.) <br />6, Site/Facility/Business Name (Include DMA): <br />7. Site location: t7 / c a+1 <br />Street <br />City State Zip County <br />8. (a) Federal Employer ID (b) Board of Equalization Fee A=unt Number Q,'- k -M 10 1 -•0 � 29, <br />(b) is only required from generators of greater than 5 tone Par calendar Year,) <br />(See instructions.) <br />g. Mailing Address:� � � � � � L-� .1�1 ��--� <br />Street <br />City State State ZIP <br />(See instructions,) <br />10. Site Contact Person; <br />First Name Last Name <br />� Contact person Address: CA <br />Street y 1 <br />City a �► state �^ Zip <br />Contact Person Phone Number: La 7 Z(,- Fax Nurnbsr, (_ z !! 0 l-S� <br />Ares Cade Phone Number Area Code Fax Number <br />Contact Person Business Emall Address -'—C �ICI S. ISJ gAln �\D F -Preferred Primary Communication; d Mail m Email <br />(See instructions.) <br />11. Legal Business Owner (not property owner): <br />iName - <br />Owner Address: � ti! r [..� CA <br />8tnet / City Btate Zip <br />Owner Phone Number: ( r� 8 . -, 7 %h Fax Number. C9 16) 4d4 1.A 1, . <br />Area Code Phone Number Area Code Fax Number <br />12, Standard Industrial Classlfloatlon (SIC) Code for the Site: <br />13. Certification! 1 eedify under <br />belief to be, true, accurate <br />GIGNATU <br />NAME (print) <br />Number) <br />or law that the inforrilation on this document was prepared to the beat of my knowledge and <br />DATEd <br />TITLE <br />