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State of California - California Environmental Protection Agency Department of Toxic Substances Control - GISS P.O. Box 806, Sacramento, CA 95812-0806 CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line -by-line instructions carefully. To Check on the status of your request, go to www.hwts.dtsc.ca.00v and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) 1. 1 am applying for a new permanent California ID number as a hazardous waste: [-] Generator Transporter Reason for new number. A. F1 Never had a number B. ❑ Business moved C. ® Legal owner of business changed if your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) For existing ID number. C A L2_ C2_ 0 0 L E] 2. 1 am updating the mailing address and/or contact information only. ® 3. 1 am inactivating this ID Number. 4. 1 am reactivating this ID Number. rr—\jl 5. 1 am changing the business name only, no ownership change. 6. Site/Facility/Business Name (Include DBA): 7. Site Location: (See instructions.) City State Zip County 8. (a) Federal Employer ID Numbe" is only required from generators of greater than 5 tons per calendar year.) h 9. Mailing Address: 1H 5 So L, to e r=A, V1 +-r-1-e(See instructions.) Street- C 'r City State Zip 10. Site Contact Person: Contact Person Address: M First Name Last Name (See instructions.) Contact Person Phone Number: (�) 441S — DLALA"t Fax Number: wl ti&s -11"6 5211 Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: t�W1N1 ,� `f G1. .GDM Preferred Primary Communication: Wmail ❑ Email 11. Legal Business Owner (not property owner): (See instructions.) Owner Address: I "'7 JO QVIn L_l in c_a JVD D+oM-V,41 lC; f -f 17d�.5 Stree City State Zi Owner Phone Number. YA5-d4�q Fax Number. �� ytA-�iCo1 Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification (SIC) Code for the Site: '3 5 0 ` (4Dicit Number) (See instructions.) 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, ccur a n f CC SIGNATURE DATE_®/ NAME (print ).ac�Yt+r h TITLE Cry PHONE'