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State of California—California Environr, ..al Agency D,. _ment of Toxics Substances Control <br /> 1 JUL 11, 2DID <br /> .A <br /> Linda S.Adams <br /> Secretary for Certified Appliance Recycler Application <br /> Environmental Protection <br /> Please submit to: <br /> Department of Toxic Substances Control <br /> Attn: Consumer Products Section- CAR application <br /> 1001 "1" Street, 11th Floor / <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> Or <br /> CAR@dtsc.ca.gov <br /> If you remove"materials that require special handling" (MRSH) from a major appliance you need to provide evidence <br /> to a scrap metal facility that you are a Certified Appliance Recycler, pursuant to Health and Safety Code Section <br /> 25211 et seq (AB 1447, 2007). <br /> Once a certificate is issued, DTSC will notify the certified uniform program agency (CUPA) in your jurisdiction <br /> responsible for inspecting the certified appliance recycling facility. <br /> Certificates issued will be valid for three years. Once your certification has expired, you are no longer a Certified <br /> Appliance Recycler. <br /> Please note:Any changes to the information provided on the Certified Appliance Recycler Application must be <br /> submitted to DTSC in order for the certification to be valid. <br /> 1. Business Information , \ <br /> Business name under which the applicant operates: � \�11 c� N001 1 ayl( e- <br /> Physical <br /> e.Physical Address: aUS ) (�C1 ��DC�- U� 01 2-0 �r <br /> Mailing address.. �� `� �� 0CTAGbD 4C\�-SIJ C-V� <br /> Business Phone number: ��J C/I `� 5� ` <br /> Business owner name: C 1 ' n - 2 <br /> Owner Address: 6�� \ CA- <br /> Owner Phone number: /l�� ' 'L 2���� Email address(if available): I'`C,W�01� I A 100 <br /> 2.) Hazardous Waste generator identification number: <br /> 3.) Is your organization required to obtain a storm water permit? ❑ Yes ❑ No <br /> 4.) Is your organization required to file a hazardous materials business plan? ❑ Yes ❑ No <br /> 5.)Tax identification number, assigned by the Franchise Tax Board: <br /> 6.)Attach a copy of a business license to this application. <br /> 7.) If applicable, attach a copy of conditional use permits issued by the appropriate city or county to this application. <br /> DTSC 1428(05/01/2009) page 1 of 2 <br />