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RECEVED <br /> Stafa of California- ;Caiifomis Environmental ProtectionDepartment of Toxic Substances Conbal-G1SS <br /> 2010 <br /> 5 P C Box 806,Sacramento,CA 95812-M <br /> LUTL <br /> - : CALIFORNIA HAZA � � ` NENT ID NUMBER APPLICATION <br />} Please type or nea I ! h a line-by-tine insnetiors carefully <br /> To ct,ea on the status of your request.go to and dick on Reports. _ <br /> t Cheri as that apply. (Sea estnxtkx►s.j <br /> !. i ani applying for a new Perrnanent Califomia ID number as a hazardous waste: R Generator (3Transpoler <br /> Reason for new number. A a Never had a number B. [] Business moved C. [3 Legal owner of business changed <br /> !�YOW business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br /> TO SIATU§ (See lnstrtxUons.) <br /> For aotisiing ID number: C A <br /> '. <br /> 132. 1 arrr, updating the rr,ailirg address and/or contact information only <br /> i t E3 3. 1 arr..inactivating this iD Number. <br /> <. 1 am reactwating this 10 Number. <br /> 6. 1 am changing the business name only.. no ownership change. <br /> (See instrucgwa) <br /> 6. S /Faality/Business Name(inriuda DBA).)., Cj N. Uctr��4 ` 1 q �� ��� (-�j�' �.•c c>:z, <br /> 7. She Location x-11 t i �� �0��' t• �e� <br /> fi. ' <br /> Street n C <br /> Cityr )! r state Zip County <br /> S (al)Federal Employer ID Numbe?.,4 (b)Board of Equalization Fee Account Number <br /> r ((b)is only required from generakn of greater than 5 toms per calendar <br /> N L C (��( (See insovcdions.l , <br /> 9. MailingAddress: --� -� ' .O �. <br /> street q <br /> c4ty state Zip I <br /> r <br /> K. <br /> (See instruction&) <br /> 1d. Site Contact Person: �tl� VL �GC)ZlAr cG <br /> First Name Last Name <br /> Contact Person Address: '' � C <br />�. Stnsef cA 5-.k ll 1 I <br /> 9` City _._ state Zip E <br /> Contact Person Phone Number ( ` � L Fax Number (__l <br /> Area Code Phone Numbw Area Code Fax Numoer <br /> I Contact Pe,wn Business Email Rddreaa Preferred Primary CommunicationMtalt •Emeii <br /> r; (See ink.) <br /> i <br /> 11. Legal Business Owner(not property owner): '1 rV <br /> Owier Address 4' rl`` me �' jLLrl �t�t� L 1~lLi � <br /> Street 4 �, Cfty StRAI Zio <br /> Owner Phone Number. L r �' �� Fax Number. — <br /> '' Area Code Phone Number Area Code Fax Number <br /> tndustrial Classification(SIC)Code for the S+te t (4-Digit huriDer) (Ses rnstrupai6ons.) <br /> 13. CArtiftcation: I lordly under psna#y of law that the infarmaboo on this document was prepared to the best of my krow'a�wye and <br /> belief to be, true,accurate and complete. , <br /> SlaWTURE i?ATE�.,� <br />' t (Phut? �53 ,t-�jo,t� a�u TrTLE .�5 _ PHdNEt ' <br /> x <br /> - <br />,r- 7 <br />