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to of California-California Enviro rotection Agency Dep. oxI.Substances Control-GISS <br /> P.O.Bo Sacramento,CA 95812-0806 <br /> �Elm ' <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 /> 01 To check on the status of your request,go to www.hwt§.dtse.ca.gov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑Generator ❑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 per month,contact US EPA for a federal ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number. CA T- 0Q G A J t— <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. <br /> 4. 1 am reactivating this ID Number. <br /> ❑ 5. 1 am changing the business name only,no ownership change. <br /> .� (See instructions.) <br /> 6. Site/Facility/Business Name(Include DBA): t- <br /> •7. Site Location: <br /> Street <br /> 11" <br /> City- State Zip County <br /> 8.(a)Federal Employer ID Number (b)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: �. <br /> Street <br /> City State Zip <br /> -c' I / (See instructions.) <br /> 10. Site Contact Person: ^4 D t'I Yl i^4!jh <br /> First Name Last Naft <br /> Contact Person Address: /5'��, li:G i 5'5 f l/!u l <br /> Street <br /> City Stater Zip <br /> �� /l <br /> Contact Person Phone Number: M) l�3� �J Fax Number. (,� fig ! <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: IVZ/� Preferred Primary Communication:Eg Mail ❑Email <br /> ---��--/ C� lG j (See instructions.) <br /> 11. Legal Business Owner(not property owner): '�1C� h f""7�� <br /> Owner Address: SSI W Gt S5 Nam® Ccfx�f <br /> StreetSta <br /> ,r City te Z'Owner Phone Number. ('!J g3� �1 ?j Fax Number. N ) 53.f- -Sy <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard industrial Classification(SIC)Code for the Site: (4-Digit Number) (See instructions.) <br /> 13. Certification: /certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be,true,a urate a d complete. <br /> SIGNATURE DATE,�`�� <br /> NAME(print) TITLE �Zt3N7 PHONES <br /> DTSC Form 1358(8/08) <br /> TRANSMISSION VERIFICATION REPORT <br /> TIME 03/15/2010 03:41 <br /> DATE,TIME 03/15 68:41 <br /> FAX NO./NAME 19162554703 <br /> DURATION 00:00:49 <br /> PAGE(S) 01 <br /> RESULT OK <br /> MODE STANDARD <br />