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State of California-California Environs it Agency Oep. ani of Toxics Substances Control <br /> Ur4a S.Adams <br /> Savetaryfof Certified Appliance RecvclerApplication <br /> EnworementaiPeoloeton MC 65 lull <br /> Please submit to: �, ,/ <br /> Department of Toxic Substances Control 1;���O v 12—/2- - /.3 <br /> Attn: Consumer Products Section-CAR application r <br /> 1001 "1"Street, 11th Floor <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> Or <br /> CAR@dtsc.ca.gov <br /> Before you may remove"materials that require special handling'(MRSH) from a major appliance, you must be <br /> approved as a Certified Appliance Recycler, pursuant to Health and Safety Code Section 25211 et seq (AB 1447, <br /> 2047). You must also provide evidence of your CAR status to scrap metal facility. <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. In order to continue operating as a CAR, you must renew your certification before the expiration <br /> date. <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 /> X4,7 jo <br /> (�Ronowal for CAR Number.. ?.3 Please note: Entire application mu t be completed, <br /> 1. Businose Information <br /> Business name under which the applicant operates:_ 0 1 V QL1 AAA .5,61(014 E e—XC4146_ ��C, <br /> Physical Address: �,2,t�p L �'Y', .s ,u Cof9.526 <br /> Mailing Address: �LL.K-Al�-)O, <br /> Business Phone Number: ( `�� �yy y.s, Business Owner Name: PAkAl <br /> - <br /> Owner Address: -3200 S . F L paX_,# P 4 :5 77 1" 7G f PS A) <br /> Owner Phone Ntimber.fXOq Email Address (if available): <br /> 2.) Hazardous Waste generator identification number._ C#e_ C�00 is-S y/r <br /> 3.) Is your organization required to obtain a storm water permit? (o 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. `1i1�" ,Zo <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(11/0412010) page 1 of 2 <br />