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09/28/2004 09:30 FAX IM005/008 <br />P <br />Slate of Cslifornia — California Environmental Protection Agency Department of Toxic Substances Control <br />P.O. Box 606 <br />Sacramento, CA 45$12-0906 <br />California Hazardous Waste Permanent M Number Application <br />Please retiety the line -by-line instructions carefully and complete all penes on the application, <br />New Number Reduests. Check all that apply, {See instructions.) <br />[ ] 1 • I am applying for a new permanent California ID number as a: [ ] Generator [ ] 'Transporter <br />Reason for new number: A. [ ] Never had a number B. [ ] Business moved C. [ ] Legal owner of business changed <br />Cb mars to Status or Information. (See instme dons.) <br />For ID number: C A L2 000 /Y$"7✓9? <br />[ ] 2. 1 am updating the mailing address anator contact information only. <br />[ ] 3. 1 am inactivating this ID Number. <br />,K4. I am reactivating this ID Number. <br />[ ] 5. I am changing the business name. There has been no ownership change. <br />6. This site is a: [ ] Conditionally Exempt Small Quantity Generator ofRCPA Waste (See instrucrions.) <br />�Q Generator of less than 1,000 kg/month California only waste ' <br />[ J Generator of greater than 1,000 kg/month California•only waste <br />7. Site/Facility Name: ,Z101V t 09 XIS C6. <br />8, Site Location: 2 ®71 ,4r• ZONES SNF <br />,�PS .4DN C,* . 95.3,E c7 <br />City State . Zip County <br />(See insrriections.) <br />9. Mailing Address: <br />S,c`3`LDN G9- 9'5-3.0 <br />City State Zip <br />C , ZW �„ S O �,yl <br />(See Instructions.) <br />10. Sitc Contact Person: 1�G�,��N / d � <br />Contact Person Address: F �F 7L� Ld l /tel U,e- <br />Street <br />City State Zip <br />Contact Person Phone Number: Q!Lf) —2 f 0-2 f D 8 Fax Number: fog <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business Email Address: <br />Preferred Primary Communication: bt Mail [ ] Email <br />11. Legal Business Owner (not property owner): �l Q�, k itf% ! / e insrruetions.J <br />Owner Address: 2.5071 It-- J�peIVKIS- Ch 9.532 4 <br />Street City State Zip <br />Owner Phone Number: (•�09 S 3 8- s /so <br />Area Code Phone Number <br />12. Standard Industrial Classification (SIC) Code for the Site: 4,D' it Number) (See ltrsrrucdons. <br />DISC 1358 10/03 <br />