Laserfiche WebLink
State of California—California Environmental "ntection Agency Department of Toxic Substances Control-GISS <br /> Reset Form ?.0. Box 806,Sacramento,CA 95812-0806 <br /> • Print <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly print in ink. Please Feview the iine-by-line instructions carefully. <br /> To check on the status of your request,go to wwvi.hwts.dtsc.ca.ccv and click on Reports <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> 1. 1 am applying for a new permanent California ID number as a hazardous waste: [] Generator F Transporter <br /> Reason for new number. A. R Never had a number B. ❑ Business moved C. [] Legal owner of business changed <br /> If 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 '2 Q �( p <br /> n 2. 1 am updating the mailing address and/or contact information only. <br /> 3. 1 am inactivating this ID Number. <br /> 4. 1 am reactivating this ID Number. - I <br /> 5. 1 am changing the business name only, no ownership change. <br /> 6. Site/Facility/Business Name(Include DBA): C (See instructions.) <br /> `/Zy«/tip 4-�C <br /> 7. Site Location: yg Ste. T jN D/�1� <br /> Str et <br /> I pFJ'vt C.4 _j r) a i n/ <br /> cityC��/ / Zip County <br /> 8. (a) Federal Employer D Number /`7 -,?&/q&.2. 7Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> 9. Mailing Address: <br /> Lo, (See instructions.) <br /> Stree <br /> City State Zip <br /> Q� r� C 9 &,/& (See instructions.) <br /> 10. Site Contact Person: �/ 1 n <br /> First Name Last Name <br /> Contact Person Address: 02--7 / "_7•,S -S,, . &-r�� <br /> Street <br /> k —3 <br /> city State Zip <br /> Contact Person Phone Number. (Z z�j q— C//9 7 Fax Number: LO [ )_ ,;7"9 R — Z D°7/ <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: C 1 19r� �/- iYIC /'Prr41-1ed Primary Communication: ❑Mail mail <br /> 11. Legal Business Owner(not property owner): /} _y% �� J6it,l� (See instructions.) <br /> Namen © <br /> Owner Address: yg <br /> Street zip <br /> pCuy <br /> C7 <br /> Owner Phone Number: 7 Fax umber.. (,R&tate 9 - 20 7/ <br /> Area Code Phone Number Area Code Fax Number <br /> F12. Standard Industrial Classification (SIC) Code for the Site: (4-Digit Number) (See instructions.) <br /> 13. Certification: I certify under penalty 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. <br /> SIGNATURE DATE <br /> NAME(print) b r_�n Ci TITLEPHONE.Z©� <br /> DTSC Form 1358(6/08) <br />