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State of California-California Environm 'Protection <br /> Q Department of Toxic Substances Control-GISS <br /> �*•��r P.O.Box 806,Sacramento,CA 95812-0806 <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 our r uest, oto www hMs.dtsc,ca, ov and dick on..Reports. <br /> L�NLE�NUR RE UESTS Check all that apply.plying for a new permanent California ID number as a hazardous waste: >4enerator ❑Transporter(See instructions.)r new number: A. ❑ Never had a number 8. ❑ Business moved C. ❑ Legai owner of business changeds generates greater than 700 kg of RCRA hazardous waste per month, call(415)495-8895 for a federal ch number. <br /> CHANGES S T�STAT S OR OFNI RMAT Np( FpR AN EXISTING ID NUM ER <br /> —.... <br /> For existing 10 number: C A <br /> ❑ 2. 1 am updating the mailing address and/or contact info -- RECENEQ <br /> U 3. I am inactivating this lD Number. nformation only, <br /> 4. 1 am reactivating this ID Number. JUN 6 2014 <br /> i <br /> L 5_- 1 am changing the business name only, no ownership change. <br /> ENVIRONMENTAL HEALTH <br /> �i- <br /> 6. SiteiFacllityfBusiness Name(Include DBA): ......t � � C, <br /> + a!_} ( '' ;rs-; gcalendar <br /> 7. Site Location: <br /> tr I ! \ <br /> city C�.?Z� <br /> i8.(a)Federal Employer ID Number { , tatezip Cou" (b)Board of Equalization Fee Account Number <br /> from generators of greaterthan 5 ton <br /> 9. Mailing Address: I`'1�1 --- <br /> i <br /> Street, I ��� C (See instnrctidns.) <br /> -- ��C.rt <br /> state <br /> ..._____.... _ p <br /> 10. Site Contact Person: n ?(r (See instructions.) <br /> First Name '� Last Name <br /> Contact Person Address: �_ r <br /> I I <br /> �nyy : C11� c — <br /> I ate Zip <br /> Contact Person Phone Number: �t 0 t l�t' � l� � � <br /> (_.—U n �-- Fax Number: �?. -7 V 7 q <br /> Area Code Phone Number Area Code Fax Number f <br /> Contact Person Business Email Address: <br /> a` f t�!4�i;c�11Z.� f nQt <br /> Preferred Primary Communication: o Mail X-Email <br /> 11. <br /> Legal Business Owner/(not property owner): { ' '� 1`�r)IM (See instructions.) <br /> Owner Address: I { / ILC <br /> r <br /> -fir-- <br /> Street Lr t C f <br /> Owner Phone Number: _ /�/ I 1 l� City State��. �. <br /> ---_� [ 1 Fax Number: Area�yCo�de Y�F i��� <br /> —.... <br /> Area Code Phone Number (-�'� <br /> _Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: C <br /> — � ..L Y_ ! (4-Digit Number) (See instructions)] <br /> 13. beliCertification:obe1 certify u r penalty of law that fhe information on this document was prepared to the best of my knowledge and <br /> belief to be, t apt aid and corn <br /> SIGNATURE "-t "—" <br /> OATS j <br /> NAME(print) i t ; n r <br /> PHONE_ f;t, <br /> DTSC Form 1358(10/12) -- <br />