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I r State of California-California Envir nmer rotection Agency Department of Toxic Substances Control-GISS Reset FOrirn' P.O.Box 806,Sacramento,CA 95812-0806 CALIFORNIAHAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line-by-line instructions carefully. To c eck on the status of your request,go to www.hwts.dtsc.ca.gov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) 1. I am applying for a new permanent California ID number as a hazardous waste: Generator []Transporter ` Reason for new number: A ® Never had a number B. E] Business moved C. u Legal owner of business changed If your business generates great r than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. CHANGES TO STATUS OR INFORiMATION FOR AN EXISTING ID NUMBER (See instructions.) For 'Xnumber:r: C❑ 2. the iling ddress and/or contact information only. ❑ 3. g this IDN mber. ❑ 4. g ' IDN mber. ❑ 5. the busine name only, no ownership change. 6. Site/Facility/Business Name(I iclude DBA): -h2t4__, C_kl, U'k-kf! (See instructions.) 7. Site Location: Lf L4 G 1J , Y l'(1—k Street , s C4_4,,., City State Zip County 8. (a) Federal Employer ID Numb r Board of Equalization Fee Account Number ((b)is only required from generators of greater than 5 tons per calendar year.) (See instructions.) 9. Mailing Address: C, � - fir- pIf Lac. --�a' (S-C vo( Street S c"k Ivy. GA- c 0", City State Zip 10. Site Contact Person: J U /)-/ (See instructions.) First Name Last Name Contact Person Address: . � Lf G treet Lk4-^, q 5G Ci y State Zip Contact Person Phone Number O / i 2 Fax Number: (� Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: e__� Preferred Primary Communication:®Mail ❑Email (See instructions.) 11. Legal Business Owner(not property owner): �'I H So S i�✓ y /-/ Name Owner Address: 2r2 E- - G Street City State zip Owner Phone Number: 2:f KO r (q 1 "L Fax Number: (14 Q LlX-15- Area ode Phone Number Area Code Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: �� L (4-Digit Number) (See instructions.) 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true, accurate and complete. SIGNATURE DATE NAME(print) TITLE PHONE DTSC Form 1358(04/12)