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State of CallPomla-Callfomla ErMronmeMal Protection Agency paparhnanl aT Toalc Substances Conbol <br /> Trenaporte8on Llnit <br /> 8800 Cal Canter Drlva,Sacramanlo.CA 95826 <br /> PM1one(9'16)940-7145 Fax(9t8)266-8436 <br /> HAZARDOUS WASTE TRANSPORTER REGISTRATION APPLICATION <br /> 1. Nemo oT Legal 6ntlty(IntllWtlual.PartnaraM1lp.Corporagon.or Limilad Liability Company): 2- Transporter Raglatratlon Number <br /> (If renewal or ralmtelemeng <br /> 3. Buslneas Nema(SM1ow tl.b.a.name,above name axadly as Il will appear on ra9letrallon;same name or 4.Application Type(cM1acK one): <br /> hademark Is raqukad on all vehicles): V Naw V RalnstetamaN <br /> V Renewal H Mltlyaer Amendment <br /> 5.Buain¢sa Address Number/Sires[ C)ty County/Provinca State/Gauntry Zlp/Postal coda <br /> 0.Melling gUtlrove(IT dlflarent)P.O.BwUSlreet Clty County/Provinca Stela/Country 21p/Postal Cotler <br /> 7e.TelapM1one Number (Ext Number) 6. lYansportar Idanaflcatlon Numbart Lls[all of tM1¢12-cM1aractar Itlanllgcagon numbers that your buslnena <br /> sas to transport M1azarHous waste. IT necessary, Ilst additlonel Idan110celicn numbers on a a¢parMa <br /> shoal. <br /> Tb.Fex Number <br /> Tc.E-mail Atltlre88 <br /> 8. Otnar Buslnesa Atldrese(as)-Llat all locatlona Trom wh1eM1 you will oparvta urMer thio reglaha[lon: <br /> (If necessary,Iist etldlllonal bualnesa etldr¢asas on a aepamla sM1ealJ <br /> Number/Sln=_et CI CouN /Provinca S[vla/Count 9 oetel Cotler <br /> t0.Ownamhlp of Buslnav(CM1ack ane): <br /> b Sole PropdataraMp b PaltnarsMp V Corporallon V Llmkatl Liability Comparry V OIM1er <br /> If a Sole Proprla[orsM1lp or PannaraM1lp,Ils<nama(s)or tllle(s)of all members.It you have no Callfornla locations,Inclutla an Agent For Service oT Process. <br /> IT a Corporation or Llml[ad Liability Comparry,Iist name(e)arq tlge(a)of offlcars Inclutling Aganl Tor SeMca of Procasa. <br /> Name Tltla <br /> Name and Atldrese of Agent far Sarvlaa of Proaasa; <br /> Nota:Transportation of hazardous waste without proper registration and public/lability Insurance Is a violation of the <br /> Health and Safest Coda,Sections 25'163 and 25469 and ma sub act ou to si nificant penalties. <br /> 1L I understand vnd will comply with all lM1e applicable M1azartloua waste hanaporta[lon requlremanta Including Chapter 6.5, OlWslon 20, M Ura Cellfarnla <br /> Health entl Safely Cotler: CM1aptar 13. DlWalon 4.5, Titla 22, CalHomla Code of R¢9ulatlone; and federal laws end regulations govaming tM1a use of <br /> manifests. 1 cartlry under penalty oT pe Jury to[M1a accuracy oT ell alafemeMs made herein. <br /> Name antl Tlila of AutM1orizatl Rapresentalive(print or type <br /> sl newre MAMhorla¢tl Ra r antauve Use blue or other non-black ink. Dale <br /> DO NOT WRITE BELOW THIS LINE FOR DTSC USE ONLY <br /> DTsc 1sT rgg <br />