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I <br /> State of California-California Environmental Protection Agency Department of Toxic Substances Control <br /> Certified Appliance Recycler Application <br /> Submit to: <br /> Attn: Universal Waste Section <br /> Department of Toxic Substances Control <br /> Hazardous Waste Management Program <br /> 1001 "1"Street, 11th Floor <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> (916)445-6130 <br /> If you remove'materials that require special handling'from a major appliance, after January 1, 2006 you will need <br /> to provide evidence that you are a certified appliance recycler, pursuant to Health and Safety Code 25211 (AB <br /> 1447, 2007). <br /> If you wish to operate as a certified appliance recycler you will need to submit this application to the Department of <br /> Toxic Substances Control (DTSC),to obtain certification. <br /> 1.) Business name under which the recycler operates: <br /> Facility address: <br /> Applicant name: CO rte v' OZQ <br /> Phone number: <br /> 2.) Business owner information: <br /> Name: 'NJ <br /> Address: `) Ydksly l 4( D�- <br /> <3+c P_ , c,AgI'LR O(, <br /> Phone: 9L <br /> 3.) Hazardous Waste generator identification number: (EPA ID#) C k duo 2R2 X33 L j V <br /> (If required.If you need to obtain a California EPA ID#complete DTSC Form 1358.) <br /> 4.) Applicant has filed an application for a stormwater permit? YE NO <br /> Is the applicant required to obtain a stormwater permit? vEs /; No <br /> 5.) Applicant has filed a hazardous materials business plan? 3y �1 No <br /> Is the applicant required to file the plan? YES I N4 <br /> DTSC 1428(1/25/2008) 1 of 2 <br />