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STATE OF CALIFORNIA Department of Resources Recycling and Recovery <br />USED OIL COLLECTION CENTER CERTIFICATION APPLICATION (CalRecycle) <br />CalRecycle 29 (Rev. 6/2012) <br />INSTRUCTIONS. Print in ink or type. Submit a separate form for each location. Use N/A to indicate any items that are not applicable. <br />1. APPLICATION TYPE (Check One) <br />❑ Initial New Application <br />❑ Recertification Application Certification Number (CalRecycle will issue this Certification Number for initial applications). <br />11. COLLECTION CENTER INFORMATION <br />Name of Business (as seen from street) <br />Street Address (physical location of oil collection center) <br />City <br />County <br />Zip <br />Mailing Address (if different than street address) <br />City <br />County <br />Zip <br />Contact Person's Name <br />Contact's Phone Number <br />Contact's Fax Number <br />EPA Hazardous Waste Generator Identification Number <br />Total used oil storage capacity (in gallons) <br />Used Oil Filters Accepted? <br />❑ YES ❑ NO <br />Description of physical location of collection center; including nearest cross streets: <br />111. OPERATOR INFORMATION <br />Operator's Name <br />Operator's Mailing Address <br />Operator's E-mail Address <br />Zip <br />Operator's Contact Name Operators Contact Phone Number <br />Federal Taxpayer Identification Number (Employer ID#) Operators Contact Fax Number <br />Does the center operator own or operate a used oil hauler business? ❑ YES ❑ NO <br />Does the center operator own or operate a used oil recycling facility? ❑ YES ❑ NO <br />IV. ORGANIZATION TYPE (Check One) <br />A. For Profit <br />❑ Individual (Attach copy of fictitious business name statement or business license). <br />Circle the type that best describes your site: Auto Service, Commercial Oil, Dealership, Fleet <br />Management, Marina, Parts Store (no auto service), Parts Store (with auto service), <br />PHHW/Landfill/Transfer Station, Quick Lube, Travel Center, Wrecking. <br />❑ Corporation (Write the exact corporate name and number as assigned by the California Secretary of State). <br />Corporation Name & Number. <br />❑ Partnership (Attach a copy of current <br />partnership agreement). <br />❑ Husband and Wife co -ownership <br />(Provide both spouses' names in Section <br />V. Declaration and Signatures). <br />B. Non Profit <br />Attach a copy of your tax-exempt status letter from the Federal Internal Revenue Service or the State of California Franchise Tax Board. Non-profit <br />corporations may provide a letter confirming tax-exempt status or may write below the exact corporate name and number as filed with the California <br />Secretary of State. <br />❑ Corporation name & number: <br />❑ Church ❑ School ❑ Youth Group ❑ Senior Citizen Group ❑ Other (Explain) <br />C. ❑ Local Government Agency (Attach a copy of authorizing letter or resolution from the governing body) <br />D. ❑ Other (Public School District, etc. (please describe) <br />Continued on reverse <br />