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otate oT 1-amornia-Ualitornia Environmo rotection Agency 0 ---�- <br /> P.O.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 Bine-by-line instructions carefully. <br /> To check on the status of your Tgnest,go to www.hwts.dts2.ca.gov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> 0 1. 1 am applying for a new permanent California ID number as a hazardous waste: 0 Generator 0 Transporter <br /> Reason for new number. A. 0 Never had a number B. 0 Business moved C. 0 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 INFORMA71ON FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number. C ® L 0 0 0 a 1) 2- <br /> 0 2. lam updating the mailing address and/or contact information only. <br /> 0 3. lam inactivating this ID Number. <br /> 110"f 4. lam reactivating this ID Number. <br /> 0 5. lam changing the business name only,no ownership change. <br /> (include DBA): U (See instructions.) <br /> 6. Site/Facility/Busi ss,Name <br /> 7. Site Location: <br /> tr <br /> City— State Zip County <br /> 8.(a)Federal Employer ID Number (b)Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> 9. Mailing Address: (See instructions.) <br /> Street— <br /> Db <br /> City State 'zip <br /> (See instructions.) <br /> 10. Site Contact <br /> First Name Last Name <br /> Contact Person Address: <-k-vv-� 0 t--, Cj <br /> Street(4 (_(C JTK � r . <br /> City StRaTe Zip <br /> Contact Person Phone Number: Q&w -/--I Fax Number: cac�-7 �Zy 6 Z <br /> Area Code 15-hone Number Area Code Fix Number <br /> A I' <br /> Contact Person Business Email Address: O'Preferred Primary Communication: ail o Email <br /> (See instructions.) <br /> 11. Legal BusinessOwner(not property owner)* Ivy, <br /> 01 <br /> Owner Address: ( N- -?Tj-e�- <br /> Street —cityState <br /> Owner Phone Number: Fax Number <br /> Area Code Phone Number Area Code Fax 9umber <br /> 12. Standard Industrial Classification(SIC)Code for the Site: (4-Digit Number) (See instruction <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,"--,accurate d /ete. <br /> SIGNATURE DATE 7Adhif <br /> --77--- <br /> NAME(print) TITLE 1"M6.17a PHONE <br /> DTSC Form 1358(6/08) <br />