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(IIL) <br />State of California - C if rniig Environmental Protection Agency Depbrtment of Toxic Substances Control - GISS <br />-�1 f ` P.O. Box 806, Sacramento, CA 95812-0806 <br />Ij11U'M�(:1-L a� -C-3 V <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 vour request, qo to www.hwt_s_dtsc ca.gov and click on Reports <br />NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br />L 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter <br />Reason for new number. A n Never had a number B. ❑ Business moved C ❑ Legal owner of business changed <br />If your business generates greater4han 100 kg of RCRA hazardous waste per month. call (415) 495-8895 for a federal ID number. <br />CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER <br />For existing ID number C A L 0 C' 0 <br />D 2. 1 am updating the mailing address and/or contact information only. <br />❑ 3. 1 am inactivating this ID Nu ber <br />J, 4. 1 am reactivating this ID Number. <br />/❑_ 5. 1 am changing the business name only, no ownership change. <br />c <br />6. Site/Facility/Business Name (include DBA) <br />7 Site Location. _ `? <br />N 0 - <br />Street I <br />City <br />8 (a) Federal Employer ID N <br />ej- <br />9. Mailing Address. �U. <br />Street <br />(See instructions.) <br />VI r e (See instructions.) <br />State Zip County <br />(b) Board of Equalization Fee Account Number N�r� <br />) is only required from generators of greater than 5 tons per, calendar year) <br />State Z1 <br />10. Site Contact Person. LC e I= I c� 6� C <br />Fi t Name LAast Name <br />Contact Person Address: �� �/ C-� lit —A \j <br />(See instructions.) <br />(See instructions ) <br />o�{eeLr A,t C A G1�1-)4G <br />City State Zip <br />Contact Person Phone Numbe . ( ZC,(o 3 39 -t9 it, Fax Number. (Wh 3 Y� - t Cj t Z <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business Email Address: +t X1 i-at_6C;.7d ��° '�1c�kY' I '`-Preferred Primary Communication: Mail mail <br />_ (See instructions.) <br />11. Legal Business Owner (not properly owner). t_ <br />Owner Address 3 cI .-Y� <br />Street _ 1 City State 1Zip <br />Owner Phone Number (;—�ij 33cl Nitw Fax Number (Z1.�I) 33�i- 1dl <br />Area ode Phone Number Area Code Fax Number <br />n <br />12. Standard Industrial Classification (SIC) Code for the Site. 1 9 (4 -Digit Number) (See instructions.) <br />13. Certification I certify under <br />belief to be, tr ! accyr�ate a <br />SIGNATU <br />NAME (print) L 15�- C_t ) <br />Fnrm 1358 tin/121 <br />of law that the information on this document was prepared to the best of my knowledge and <br />TE � /3- f 5 <br />TITLE' kh. he- PHONE 2C"i 33`1 - I cr /L <br />