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State of California — California Environments ction Agency partment of Toxic Substances Control - GISS <br />INWEV� 7,77" 00. Box 806, Sacramento, CA 95812-0806 <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 />To check on the status of your request go to www.hwts.dtsc.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: C A <br />❑ 2. 1 am updating the mailing address and/or contact information only. <br />❑ 3. 1 am inactivating this ID Number. <br />JR'4. I am reactivating this ID Number. <br />❑ 5. 1 am changing the business name only, no ownership change. <br />e- (i (See instructions.) <br />6. Site/Facility/Business Name (Include DBA): <br />7. Site Location: <br />8. (a) Federal Employer ID Number, <br />Board of Equalization Fee Account Number <br />is only required from generators of greater than 5 tons <br />calendar year.) <br />n„��^ / s �� (See instructions.) <br />9. Mailing Address: `�J� "l ,aJ <br />Street <br />City _ State CCS Zip <br />10. Site Contact Person: <br />Contact Person Address: <br />LastName <br />��6� <br />'I,,\J 1G(/ <br />(See instructions.) <br />Street rk <br />City �}p , ( State Zip <br />�j <br />Contact Person Phone Number. ` 11��®2- "1 5� Fax Number: <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business Email Address: -L>t—t t( <br />CIA (L r <br />WC/4 r f mad Primary Communication: ERMail mail <br />V I %es <br />11. Legal Business Owner (not property ®I�l/ny <br />G�71� <br />'o r� <br />(See instructions.) <br />^owner): �I �n <br />Owner Address: q� l " [ J ° L <br />(mad <br />Stre�7 City State <br />Owner Phone Number: ��� �y/ Fax Number: <br />Zip �p <br />Area Code Phone Number <br />Area Code <br />Fax Number <br />12. Standard Industrial Classification (SIC) Code for the Site: (4 -Digit Number) (See instructions.) <br />13. Certification: I 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, ate and complete. <br />SIGNATURE DATE t��' 369 <br />NAME (print) f'Z TITLE �S PHONE Gf/ ( 7— <br />DTSC Form 1358 <br />