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o 0 <br />State of California — California Environmental Protection Agency Department of Toxic Substances Control - GISS <br />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 your request, go to www.hwts.dtsc.ca.gov and click on Reports. <br />NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br />arn aNpl'y'irig IN a flew peln-tallel ll VanlUllllc! 0 nurnber as a hazardouswaste: U vv-uciatur ❑ Transporter <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 permonth, call (415) 495-8895 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 -L— <br />-0- ,� � -1-RECEIVE <br />EI2. 1 am updating the mailing address and/or contact information only. <br />u <br />an, iiiaCii'vag U11S 1u INUMbei. <br />AUG <br />JO1 J <br />Y, 4. 1 am reactivating this ID Number. HVU L <br />❑ 5. 1 am changing the business name only, no ownership change.ENVIRON <br />14r:81 -L! n77)n nTA 4r k i, <br />(See instructions.) <br />6. Site/Facility/Business Name (Include DBA): <br />7. Site Location: a40" e' <br />Sii eget. <br />Ci <br /> <br /> 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:! t'�)T% <br />Street �p <br />ity ___ _ State -- Zip — <br />(See instructions.) <br />10. Site Contact Person: <br />First Name / / Last Name <br />CAP- <br />0 Contact Person Address: Lis C-C,������� <br />0 <br />StdLU- <br />r <br />Contact Person Phone Number: (-M) ' Fax Number. c C <br />Area ode hone Nu ber Are``a Cddde Fax Number <br />Contact Person Business Email Address: ( '1 ti 0 0 .Pre erred Primary Communication: W<111 ❑ Email <br />(See instructions.) <br />11. Legal Business Owner (not property owner): <br />_ i Name <br />Owner Address: 1, <br />Street /r�" City State Zi / <br />Owner Phone Number: ( ) `7�V _ Fax Number: ( e(j) <br />Area Code Phone Number Area Code t Fax Kumber <br />12. Standard Industrial Classification (SIC) Code for the Site: f _.�_ _ n_ (4 -Digit <br />13. Certification: t ceriify under penaity 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 ( Z <br />NAME (print) C CL. kn TITLE t) at! �� ��✓ PHONE(?) �6 �✓ ��U© <br />Form 1358 (1 <br />