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12/15/2017 00:05 FAX 2004 <br /> State of California—California Environmt Irotection Agency Jepartment of Toxic Substances Control-GISS <br /> �eset Form Print P.0.Box 806,Sacramento, CA 95812-0806 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT 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 reauest 50 to www.hwts dtsc.Ca,oev and click on Re crts, <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> 1. I am applying for a new permanent Califomia ID number as a hazardous waste: [] Generator FITranspQrter <br /> Reason for new number. A. 0 Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br /> l�f your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number, <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number. C A _ t_ .Z Q p q <br /> ❑ 2. 1 am updating the mailing address and/or contact information only, 1 q <br /> ❑ 3. 1 am inactivating this ID Number. Q <br /> 4. [am reactivating this ID Number. l~ <br /> a- <br /> ❑ 5. lam changing the business name <br /> <br /> DOA): C be CIA( _4AIC <br /> 7. Site Location; '2 y 9 7 / -5t°- td,S LIN kPA6 <br /> St r et <br /> cityate Zip County <br /> 8. (a) Federal Employer ID Number _��_ 1g10 ]Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> /� (See instructions.) <br /> 9. Mailing Address ��_ (� �x /_ <br /> Streepp\ <br /> City State Zip <br /> nn � (See instructions-) <br /> 10. Site Contact Person: /�� } !J C �d AJ`T <br /> First Name Last Name /� ! <br /> Contact Person Address, y <br /> Street,,t IQCJ.iIa e <br /> r City � �rr5'tate 7.� r LO <br /> ZIP <br /> np <br /> Contact Person Phone Number U 2.7 /�� �/�� Fax Number: ( _ ___5-9p9-! 2-071 <br /> Area Code Pnone Number Area Cade Fax Number <br /> Contact Person Business Email Address: T/ ` � <br /> �n / r �Yte Q� Preferred Primary Communication: ❑Mail mail <br /> (See instructions.) <br /> 11, legal Business Owner(not property owner): �7�Jd/���T <br /> �yg 7 ,Names x.(, /L�a . 1G&!qC` 9s��6 <br /> Owner Address: 7 /� <br /> Street �1 City 5tdte Zio <br /> Owner Phone Number. (L11�11 ) 7—'VQ 7 Fax Number. ( — 2-0 71 <br /> Area Code Phone Number Area Code Fax Number <br /> L12 $tandird Industrial Classification (S1C)Gode for the Situ (¢Digit Number) (See instructions.) <br /> 13- Certification: I certify under penah'y of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be, true,accurate and complete. C� <br /> SIGNATURE r DATE 6 - -U / �+ <br /> NAME(print)1/QQR; f_ji'q TITLE pr1[S c d((.t�.� PH0NE,W9-S 1 —9' 7 <br /> OTSC Form 1358(6108) <br />