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4r 'L- Z6 G State of California-California Environmental Agency ` Department of Toxics Substances Control Linda S.Adams Secretary for Certified Appliance Recycler Application Environmental Protection Please submit to: Department of Toxic Substances Control Attn: Consumer Products Section-CAR application 1001 "1"Street. 11 th Floor P.O. Box 806 Sacramento, California 95812-0806 Or CAR@dtsc.ca.gov Before you may remove"materials that require special handling" (MRSH)from a major appliance,you must be approved as a Certified Appliance Recycler, pursuant to Health and Safety Code Section 25211 et seq(AB 1447, 2007). You must also provide evidence of your CAR status to scrap metal facility. Once a certificate is issued, DTSC will notify the certified uniform program agency (CU PA) in your jurisdiction responsible for inspecting the certified appliance recycling facility. Certificates issued will be valid for three years. Once your certification has expired, you are no longer a Certified Appliance Recycler. In order to continue operating as a CAR, you must renew your certification before the expiration date. Please note:Any changes to the information provided on the Certified Appliance Recycler Application must be submitted to DTSC in order for the certification to be valid. Renewal for CAR Number: Q ,q Lf Please note: Entire application must be completed. <a,,, Vin 1. Business Information 1 Business name under which the applicant operates: Ory-,Jr_tC &�eC\-t o n.c s �-ec �,t I.�� ✓ Physical Address: 3 3 ti -Veep c- pito c C A 5 69 05 Mailing Address: ; Business Phone Number: (,k I X 311"-79'71 Business Owner Name: Ito ce Otc�rt«e*r�cv— Owner Address: �C) 6c j q� C tr'�rC�,tE" t �� J�d-7 Owner Phone Number: (ity`1 ) ! �l `�67�7 Email Address(if available): M_V`-f C��•� S ir/arfW�Lt 2.) Hazardous Waste generator identification number: V, ClIL (1900 346 3 s S� OG 3.) Is your organization required to obtain a storm water permit. [X Yes No 41- 4.) I4.) Is your organization required to file a hazardous materials business plan? [ ] Yes ❑ No ��- 5.)Tax identification number, assigned by the Franchise Tax Board: (cS�M' 16-5-7 6 f Li 6.)Attach a copy of a business license to this application. 00 7.) If applicable, attach a copy of conditional use permits issued by the appropriate city or county to this application, t f DTSC 1428(11/()4/7.010) (�(� 1� /J /j �page I� /��—�ve-