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06,'3012010 11:36 209-833-1002 TRAC'',' P01r,1ER EQUIP PAGE 01104 <br />Slate n' CalitornG.i - California Environmental Protection Agency Department of Toxic Substances Control - GISS <br />Ljtgm P.O. Box 806, Sacramento, CA 95812-0606 <br />CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br />Please type or neatly print In ink. Please review the line-by-Ilne Instructions earefulfy. <br />To Cheek on the status of yoLfr request, go to www. hwts.dt,q,qq_vand click on Reports. <br />NEW PfUMf3ER REQUESTS Check all that apply. (See instructions.) <br />El 1. am applying for a new permanent California ID number as a hazardous waste, ❑ Generator Transporter <br />R asor for naw number: A. [] Never had a number 8, [] Business moved C. [] Legal owner of business changed <br />f . ncrr f;usiness generates greater than 100 kq off -?CRA hazardous waste ner month contact t13 FPA fne .a fPrfarmi in <br />CHANGES TO STATUS OR INFORM TION FOR AN EXISTING ID NUMBER <br />creois ing ICS number: C A 0 0 Z <br />[] 2, 1 am updating the mailing address and/or contact information only. <br />[] 3. 1 aro inactivating this ID Number. <br />% 4. 1 am reaOlvating this ID Number. <br />[] 5. 1 am changing the business name only, no ownership change. <br />6. Site!Fa�:ilityf Etusiness Name (Include ORA)' <br />i. Sita I ocatlon <br />aty <br />�. a) Federal Employer ID Number ! <br />!_i <br />(See instructions,) <br />(Sae instructions-) <br />State Zip County - <br />(b) Board of Equalization Fee Account Number <br />) is only required from generators of greater than 5 tons per calendar year,) <br />by_ C� (See instructions.) <br />9 hrl�dmg Address: ��S <br />Street <br />City State Zip <br />10. Si1,_, Contact Person: U_-) PA <br />First Name <br />(See instructions.) <br />Name <br />C{mlact Person Address: <br />State <br />Cantaq Person Phone Number (ZO 8-713-1006 Fax Number: (Z-0- B 3 3 - (n 62 <br />r <br />Area Code phone Number Area Code Fax Number <br />(.:ontoct Person Business Email Adt7r [ pW ow"'Qw- T <br />referred Primary Communication: 022il Email <br />4 (See instructions.) <br />1'1. L.eyG11 BusinE!ss Owner (not property owner); Nam� A:: <br />(7wn�rr Address; <br />Street City State Zin <br />LOwner Phone Number. CIA7) 2-58 -046-t— Fax Number: <br />_ Area Code Phone Number Area Code Fax Number <br />12. c:,tanc:ard Industrial Classification (SIC) Code for the Site! <br />4-Dioit Number) <br />instructions, <br />i j. � ,emncwion: I cervPy under penalty of law that the informatlon on this document was prepared to the best of my knowledge and <br />t!ehet to be, 1r acc rate and complete, <br />SI(3rdATURE, DATE <br />NAW!• (print) _'F-T_kUt TITLE' PHONE: 7-0 - d <br />DTSC F(❑'r� 1:158 (6%08) <br />