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CALIFORN'IA D [PARTMENT OF HEALTH SERVICES <br /> s. �„' '4.11`4 c l ]I 4 i It ni <br /> APPLICATION FOR <br /> r %1 1Ff1F; , f f \ ffZf `,1F 1 1 If �71VD01 %STI f)IM't1S \1 P1 V 'Al <br /> - <br /> / For Offic• I,A• Only <br /> �} <br /> E 1` i' I . �.,J V E i'errtitt h , <br /> F, <br /> ,—i I%erse%di (Preva i=s Permit h4 f)ete ) Date Approved I! l ►'{.' <br /> r, f C ,�A— �� [XT IFr.E Y 11 j "Y)US <br /> L_J Amenriment (Currer t Permit Nn ,1, 1 6rltr, , T��.>r Fxirrea <br /> t 4 erbal {If given verbal kfrlercency Nertnit by teleILI <br /> 1 J Eli Officer <br /> J <br /> --- <br /> 4 <br /> "—"` Trans ,o <br /> I I / f <br /> '!Fr'�hilr i nia.ler' •v fernr4� ^loriri5 <br /> TO d 4 , � �'�� . �� Atl'# <br /> Please type or print clearly Provide all rr�formation reylested,ynce opui4t9p willirejult in delay or Mensal of permit Allow 15 days process lune <br /> from date of permit receipt <br /> aste Generator Nagle of F}im EPA 1D # (of ptck-up location) <br /> (F F2r'vA C'ACoon2.!!1OEQL <br /> Pick-up Address Street No City State Zip Code <br /> 2b 4 o W E s 5_�,'!_+� � ►_� S�- x��o r�i C�A. <br /> Mailing Adaress (If different than above) City State Zip (Code <br /> o S �I <br /> Appiicant (Prnt or Type) Title. + ,t S S h� <br /> to ltcant Date Telephone No <br /> 4V- 7O <br /> Proposed Hauler �.of Firm <br /> Mailing Adareas Street No or P O Box City State Zip Code <br /> 150 <br /> Hauler No EPA ID NUMBER <br /> L-2,4 r�O S 99 <br /> For additional hatftlii please use addendum sheets <br /> Proposed klmlme of F <br /> DI <br /> F_#11 Location Addreaa Street No City State Zip Code <br /> lei <br /> 3 6 i'd rj("��ao 4 <br /> , Gr3 a 7 EPA ID NUMBER , <br /> ora ditiona] facilities ]ease use addendum sheets (A <br /> TO <br /> TOXIC SUBSTANCES CONTROL PROGRAM REGIONAL OFFICES <br /> Region 1 Region 2 Repo- 3 Region 4 <br /> . 10151 Croydon Way 700 Heinc Avenue 1405 N San Fernando Blvd 245 West Broadway <br /> Sacramento, CA 95827 Bldg F,3rd Floor Suite 300 Suite 350 <br /> (916) 855-7700 Berkeley, CA 94710 Burbank, CA 91504 Long Beach, CA 90802 <br /> (415) 540-3734 (818) 567-3000 (213) 590-4868 <br /> I <br /> +Required for handling or disposal of extremely hat.ardous wastes (Secs 66570 and 66595,Title 22, CCR) <br />