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SlatR of Califomir� — CaliFornia Environmental protection Agancy <br />�� <br />L�09'°N Wdll��-,>aozozo'9l'unr,t,auail panla°a� <br />P.p, Box 808, Sacramento, CA 96812.0808 <br />.... .. <br />�__.�_ _ <br />• • � _ • � • • • � �i <br />■ • � •- <br />❑ 4, I am reactivating this ID Number, <br />5. I am changing the business name only, no ownership chs <br />8, Slte/Facility/Business Name (Include oeA): � G � <<% <br />7. Site Location; <br />S1�1i <br />(see tnstrucuons.) <br />8. (a) Federal employer ID N <br />b) Board of Equalization res Hccounr rvumoer <br />!s only requir�5d from r�onerators of greotvr than 5 tons per calendar year,) <br />.r . � ., t n/ / ., '1 � ,_ .0 V - _. ,�, (Sea Instructions,) <br />10. Site Contact Parson: <br />Contact Person Address; <br />Contact Person Phone Nwnber; (��) _� � �� <br />res Coda Phone Number <br />Contact Person 9uslness Pmail Address: <br />11. Legal Business Owner (not progeny owner): ��`. <br />�,�,r <br />12. <br />Owner Address: / � '"�,►__ � A�—� <br />Street <br />Owner Phone Number: ( ) <br />Area Code Phone Number <br />rd Industrial Classification <br />ICl Code for the Slte; <br />Name <br />_ zl(� <br />Fax Number; (�) �,��� � � 7 C' ,� <br />Area Code Fdx Number <br />�h Preferred Primary Communication: rg�Mell �-i Email <br />C.�od <br />Fax Number: (_) <br />Area Code Fax Number <br />4 -Digit Nu <br />(Sae instructions.) <br />r <br />instrc�ctlons. <br />13. Certlflcation: I certify underpenaliy of law that the Information on this document rues prs3perc�u iv uia uo�� �� ���r-�����•����- � •- <br />belief to be, tru ccurate a d mpiete. <br />DATE � S Q yC) -- <br />SIGNATURE <br />NAME (print) <br />1 iq r U' . � TITLE G��.Q PHONE���� ' � ��� <br />C rorm 1R6P. (10/12) .,..--._. __....._...----._..,, <br />5 /5 -��xa �OL9ii��60z x Qc�� tsozsszr�s��s x�xa�g wa L�: zo OZOz' LZ'unr <br />