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.lan 04 06 C9: 19p Simsmeta1 Styr, 2099490626 p. 4 <br /> State of Caiiforria-California Environmental Protection Agency Oeparmenr or Toxic Substances contra, <br /> Cerbflie,a Anpliance aRac- c!e�, aci cation <br /> j Submit to: <br /> Department of Toxic Substances Control <br /> Hazardous Waste Management Program <br /> 1001 "I'Street, t 1 tit`s Floor <br /> P.O. Box 906 <br /> Sacramento, Gallfomia 9.5912-0806 <br /> If ycu transport,deliver, or sell-discarded major appliances to a scrap recycling facility, after January 1, 2005 you <br /> will need to provide evidence that you are a certified appliance recycler., pursuant to Health. and Safety Code 25211 <br /> (.=18 2277,2004).After.jul;i ',2005:tFycu wish to opera'.e as a--aillfied apc',anc3 recycler'?ou vrill need tg ;44 <br /> this s.oplicetion to the 0epat<r ent of ToA.-Suhstarsce Control(DTSC), to obtain certificat cn.As of an:iarf 1,2006 <br /> scrap recycling`acuities will he pr4ribited from accepting s discarded mayor app'iarce=corn any personvirmc is not a <br /> certified appliance recyrler. <br /> 1.) B,_sin.ess name under which the recycler operates: (N y `l Sv+4 S' �o 1 r / tit 0--5 <br /> Applicant nsine: •n�L4.r1.__,��� ��.___ <br /> Phone rlumoer. <br /> 2.) Business owner information: <br /> Name - A—_ l <br /> Address- <br /> iv o <br /> �) /� <br /> Ptione: Z� - --" C11'I' <br /> 3.) Hazardous Waste generator identification number. (EPA ID#) <br /> (if required.V you need io obtain an EPA,'o S call:I.600.619-9542) <br /> 4.) Applicant has fled at. application`ora stormwater permit, or �e""A.ppiieant is roti raGt`red to ob?ata 2 siorrrrvater peer-tit <br /> 5.; .Applicant h39 filed a hazardous materials Fusin s-Ian: ^r <br /> ?.ppticant is r��t req;:il-ad to file tine plan. ;;apt;- <br /> 6.) Tax identification number; assigned by the Franchise'rax Board- <br /> 7.,, Attach a copy of a!�!siress license;2'"a ary conditi-nna!use by Pse appr::ipriate <br /> city or county. <br /> OTSC 1428(0421!2005) 1 6f2 <br />