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State of California—California Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> Reset Form PriP.O.Box 806,Sacramento,CA 95812-0806 <br /> nt <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 request,go to www.hwts.dtsc.ca.gov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> 117r 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter <br /> teu <br /> Reason for new number. A. [] 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 <br /> ❑ 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 Nuber_ <br /> ❑ 5. 1 am changing the busin name only, no ownership change. <br /> _ (See instructions.) <br /> 6. Site/Facility/Business Name(Include DBA): (�V ) <br /> 7. Site Location: C-Q 60 L4 <br /> SLOW D <br /> rty, 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 /> Z I V C (See instructions.) <br /> 9. Mailing Address: ` <br /> Street _ <br /> Cl- <br /> Cilli- State Zip <br /> ' � I (See instructions.) <br /> 10. Site Contact Person: t �/ l� - ro e I <br /> Fiat <br /> Name Last Name j <br /> Contact Person Address: 1 S #1 Z L C ` <br /> S t <br /> State Zip <br /> Contact Person Phone Number. ( Fax Number. S <br /> Area Code Phone Number Area Code Fax Number <br /> n <br /> Contact Person Business Email Address: 2 1 fi Preferred Primary Communication: Mail Email <br /> t e 'nstruc6o s.L <br /> 11. Legal Business Owner(not property owner): fly ( Z <br /> Owner Address: CDame •v _I - � Cc{ <br /> Stree�t � T� City A .k <br /> State. io <br /> Owner Phone Number. ,C"' ) L-1 6- 6 7l S Fax Number. (��t) C-/k � ;�7/S <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: t7 -5 3) -a (4-Digit Number) (See instructions.) <br /> 13. Certification: I certify under penally 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. 7 <br /> SIGNATURE ' > `' �1 �-� DATE 9— ( ao �l <br /> NAME(print) L 11 TITLE_,Q4+h t✓Q PHONI <br />