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09/14/2010 13:57 4082622206 PANDCAUTO PAGE 06/06 <br /> - F l oT-e Ac,' <br /> DepArlment of Toxic Substances Control-GISS <br /> State of California 1 California Environmental Protection Agency p,0,Sox 8o6,Sacramento,CA 95617-0806 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly print in Ink. please review the line-by-line Instructlong carefully, <br /> To check on the status of your request,go to www 1W d se.ca.c4_v and click on Reports. (See Instructions.) <br /> NEW NUM ER RE U STS Check all that apply. <br /> 1. 1 am applying for a new permanent California ID number as a hazardous waste: �] Generator Transporter <br /> Reason for new number: A. f-I Never had a number BE] Business moved C. E] 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 Qg INFORMATION FOR EXISTING ID NUMB R (See instructions.) <br /> For existing ID number. - <br /> 0 2, 1 am updating the malling address and/or contact Information only. <br /> 0 3. 1 am inactivating this ID Number. <br /> X 4, 1 am reactivating this ID Number. <br /> [] 5. 1 am changing the business name only, no ownership change. <br /> n (See instructions.) <br /> G. Site/Facility/Business Name(Include DBA): <br /> 7 Sita Location; <br /> Street <br /> p <br /> City State zip County <br /> 8. (a) Federal Employer ID Number (b) 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: <br /> Street nn' <br /> City State Zip <br /> (See instructions.) <br /> 10. Site Contact Person: �C P—^'II'l"— <br /> First Name Last Name <br /> Contact Person Address: IS10 - 0- 1V 20" g.e <br /> Street 15-37 <br /> CiIY state Zip <br /> Contact Person Phone Number: ( ) 1 l 7 75L_ Fax Number; ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: Proferred PrimaryCommunication:Q Mall �]Emall <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): + L ��^`o '`may<<e'�- T'�C <br /> Zv <br /> Name <br /> 3PAD, <br /> Owner Address; I PA l� <br /> `"'`" �j(t/ I�1.(ht_ t'1 • � � � <br /> Street City State zip <br /> Owner Phone Number; ( �) 2 Z S��G Fax Number. <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Slte. 0 (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) r C t 2"t'-(` TITLE 6 " PHONE 9l �/� ' fl <br /> 7 <br /> DTSC Form 1358(6108) <br />