Laserfiche WebLink
State of California-California Envir nmentak itection Agency apartment of Toxic Substances Control-GISS <br /> Reset F0 I Print P.O.Box 806,Sacramento,CA 95812-0806 <br /> CALIFORNI HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Ple se type or neatly print in ink. Please review the line-by-line instructions carefully. <br /> To ch ck on the status of your request,go to www.hwts.dtsc.ca. ov and click on Reports. <br /> NEW NUMBER REQUESTS Chck all that apply. (See instructions.) <br /> [j1. 1 am applying for a new p rmanent California ID number as a hazardous waste: ❑ Generator []Transporter <br /> Reason for new number: A ❑ Never had a number B. E] Business moved C. E] Legal owner of business changed <br /> If your business generates great r than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br /> CHANGES TO STATUS OR IN ORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number: C AL- ©� c-7, 0 -3� -5-7 _-a' f <br /> [(2. 1 am updating the mailing ddress and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID N mber. <br /> ❑ 4. 1 am reactivating this ID N mber. <br /> (] 5. 1 am changing the bus <br /> / f (See instructions.) <br /> 6. Site/Facility/Business Name(I clude DBA): C J(//I / / I// L� �CJ CI ? E— u <br /> 7. Site Location: 4 6 t t) <br /> Street /-, A <br /> C-Ify Zip County <br /> 8.(a) Federal Employer ID Num rt - O Z ) Board of Equalization Fee Account Number <br /> ((b�ate <br /> s only required from generators of greater than 5 tons per calendar year.) <br /> (See instructions.) <br /> 9. Mailing Address: /20-6 v �Y 1 G 1,-.C(-b 4�1,-.C( <br /> Stre _ . U c/ <br /> City State Zip <br /> 11 f ` (See instructions.) <br /> 10. Site Contact Person: G r ` 6(:' <br /> Fi st Name Last Name <br /> Contact Person Address: , - a lee` C-'L <br /> treet Com- , <br /> atf State cZi/p> <br /> Contact Person Phone Numb r: (7) p �y Fax Number: ( 7 ` ` ?7 <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Em it Address: Preferred Primary Communication:❑Mail ❑Email <br /> .r y% (See instructions.) <br /> I 11. Legal Business Owner(not pr)perty owner): I ��0J-��g l G�-C_ <br /> "i <br /> m C.,Owner Address: 704 C t,, C dm `' -4 W, cC n - (4 71-Y <br /> Street1,, !, City State Zio <br /> Owner Phone Number: (C� 7 Z U (- 16 V Fax Number: (� <br /> Area ode Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classifica ion(SIC)Code for the Site: _ (4-Digit Number) (See instructions.) <br /> 13. Certification: I certi d enalty of I that the information on this document was prepared to the best of my knowledge and <br /> belief to be, tru , ate and corn / <br /> SIGNATURE DATE ? L G <br /> I ` <br /> NAME(print) G <br /> IT <br /> � 6 <br /> DTSC Form 1358(6/08) <br />