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State of California - California Environmental Protection Agency Department of Toxic Substances Control - GISS P.O. Box 806, Sacramento, CA 95812-0806 CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line -by-line instructions carefully. To check on the status of your request, go to www.hwts.dtsc.ca.gov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: N Generator ❑ Transporter Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste per month, call (415) 495-8895 for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) For existing ID number: C A 1- % Ci G. •,l q I Z 3 L ❑ 2. 1 am updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID Number. 0, 4. 1 am reactivating this ID Number. ❑ 5. 1 am changing the business name only, no ownership change. 6. Site/Facility/Business Name (Include DBA): t�. �A .`tom �uyJ;��• A,,41v '?_-1 (See instructions.) 7. Site Location: Street V -.: 1 �s1 t Jul ") :gym/ 1 64lCr l City State Zip County 8. (a) Federal Employer ID Number (b) Board of Equalization Fee Account Number ((b) is only required from generators of greater than 5 tons per calendar year.) -J (See instructions.) 9 Mailing Address: VC.'� �d� �✓r) I Street (—A 9 `f City State Zip (See instructions.) 10. Site Contact Person: M 1 -S1 v) 't'JK��;, 1 First NVfie Last Name Contact Person Address: I" UC C (Jit -,le L ) Street City State Zip Contact Person Phone Number: (_) Fax Number: ( Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: n i'N 1 0NA� `l I Co L 01"C N�ijBJ 1 Preferred Primary Communication: )$ Mail ❑ Email 11. Legal Business Owner (not property owner): 1''1 Y/ FX�.n Name Owner Address: Iia E I.HNe'L ]♦ Street Owner Phone Number: (R ) Area Code Phone Number (See instructions.) City State Zip Fax Number: (3) Yt) 4(ct)" ` 1 40(L• Area Code Fax Number C 12_ Standard Industrial Classification (SIC) Code for the Site: l 10 (4 -Digit Number) (See instructions.) 13 Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true, accurate and complete. I SIGNATURE �fl tai �{� DATE NAME (print) TITLE �'.L>r<��`' PHONE/ DTSC Form 1358 (10/12)