COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

State of California-California Environmer- 'rotectlon Agency Department of Toxic Substances Control-GISS Reset Form P.O.Box 806,Sacramento,CA 95812-0808 Print CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly Print in ink Please reviewthe IIne-by-line Instructions carefully. To check on the status o/your request,go-to wvrw_hw s cttse ca aov and click on Reports _ NEW NUMBER REQUESTS Check all that apply_ (See instructions,) [] 1, t am apprying for a new permanent California ID number as a hazardous waste: L] Generator []Transporter Reason for new number. A. ❑ Never had a number S. [] Business moved C. t Legal owner of business changed If your business generates greater than 900 kg of RCRA hazardous waste per month, con act U5 EPA for a federal 0 number, CHANGES TO STATUS OR INFORM TION FOR AN EXISTING ID NUMBI"R (See instructions.) For existing ID number C /� _ � [j � � 3 2_ lam updating the mailing address and/or contact information only. E] 3. 1 am inactivating this ID Number. 4. 1 am reactivating this ID Number_ )! 5. I am changing the business name only,no ownership change. 6. Site/Facility/Businessc Name(Inducie DBA): C • �ON7'/Z ��/C (See instructions.) 7_ Site Location: .� 7 7t Crty _ a Z'P County8. (a) Federal Employer ID Number 1. oard of Equalization Fee Account Number ((b)is only required from generators of gmeater than 5 tons per calendar year.) /J /� 8. Mailing Address: (See instructions_) �� c-,� Stre •' �Crh State Zip 10. Site Contact Person: L -70 A.)& (See instructions.) First Name Last Name Contact Person Address; 02q9~I SQ Street ©L f/ - City State Zi!�� P Contact person Phone Number ( ) 7 - y Pax Number. p 7r Area Code Phone Number Area Code Fax Number - Contact Person Business Email Address: V?\ t]� ly c ae/'Pn.ed Primary Communication:[Mail mail 11. Legal Business Owner(not property owner): J (see instructions_) ,Z Name Q Owner Address: � 7S� Stregi City state Zip Owner Phone Number. 1AP �— Fax Number s S — a477/ Area Code Phone Number Area Code Fax Number [12:]S;tandard Industrial Classification(SIC)Code for the Site: �: I 13 (4-Digit Number) (See instructions,) 13. Certification: /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 l� NAME(print) TITLE—La J1 A4c1_ PHONE.2495-SV -V 7 DTSC Form 1351(6108)