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State of California-California E vironmental Protection Agency Department of Toxic Substances Control GISS P.O.Box 806 Sacramento,CA 95812-0806 Cali ornia Hazardous Waste Permanent ID Number Application Please review the line-by-line instructions carefully. New Number Requests. Check all that apply. (See instructions.) 1. I am applying for a new permanent California ID number as a hazardous waste: k Generator ❑Transporter Reason for new number: A. 0 Never had a number B. �j Business moved C. Legal owner of business changed Changes to Status or Information. (See instructions.) For ID number: C A 2. I am updating the maili ig address and/or contact information only. 3. I am inactivating this I Number. E) 4. I am reactivating this I Number. Ct 5. I am changing the bush Less name. There has been no ownership change. 6. This site is a: Ge ierator of less than 1,000 kg/month Califomia-only waste (See instructions.) Ge terator of greater than 1,000 kg/month California-only waste D C dit ovally xempt Small Quantity Generator of RC Waste 7. Site/Facility Name: 8. Site Location: Stre t. UaLj City State Zip{ County (See instructions.) 9. Mailing Address: jZ City State Zip (See instructions.) 10. Site Contact Person: ' First Nam L t Name Contact Person Address: Street *Z_ City State Zip Contact Person Phone Number: (��,, G X37C) Fax Number: Area Code Phone Number Area Code Fax Number Contact Person BusinesA Email Address: Preferred Primary Co unication: Y, Mail I Email (See instructions.) 11. Legal Business Owner(not property owner): iQ m Owner Address: l T �( Sti eet City State Zip Owner Phone Number: - Area Code Phone Number 12. Standard Industrial Classification(SIC)Code for the Site: L (4-Digit Number) (See instructions.) DTSC Form 1358(9/04)