Laserfiche WebLink
2900 Loomis Road PR0523518 <br /> July 15, 2019 Program: HW <br /> PHOTO 3: ID number a lication was filled out and faxed durin the ins ection. <br /> W MME <br /> F <br /> is-Califomle C,vlmnrnental Pmkcllon A,onryDBpnof ,,,,,or Totlo Subslnnws Control <br /> PERMANENT STATE ID NUMBER APPL&T'IONmm�mnl mformnoon NanneememR REQUESTS Chock ell thateppl.ie"'W rill ibl In ink. <br /> pply,,,franewpermanentC-1lfomiaID numberasahazerdouewaste:❑Generator ❑Transporterranew number: A.❑Nevar had a number B. ❑Business moved C.O Legal owner of business changedsgeneret�sogreaterl'han 100 kg of RCRA hazardouswasteo1/rerthenIhosehazadouswastelistedIn4(1 CFR261.5ntl(tlJ per month,p/esrse comply ata Forr_6700-12 fora federal EPA ID number. <br /> Fexisting <br /> TO STATUS OR INFORMATION FOR AN E TI G 5 ATE ID NUMBER <br /> ID number. C A <br /> pdal ng the ma ng address and/or contactmforrnation only.nactivating this ID number. <br /> activating this ID number.Reason(please reelect one): A.Jyrrificatio,Questionnaire B. O Other <br /> hsingmg the business name only,no ownership change+ <br /> �1. <br /> Siloaiy,3usiness Name(In de OBA)m - .1, d Y14Site Location:y`kl <br /> �T o� <br /> 8.(a)Federal Employ r ID Numbe - - Z p Courcy <br /> ti ~ )Board of Equalization Fee Account Number <br /> 1)is only requiredfromgenerators of,mater than 5 tons per calendar year.) <br /> 9.Mailing Address: <br /> Street <br /> cityZlo Code <br /> 10.Site Contact Person' erne!6 - r( <br /> Frst N,me �. Las,Names <br /> Contact Person Address: (-/y,(tom/�_�J`.Sp..-i_' y <br /> st 4 � �{ <br /> Cl L� State I t >rct� ip <br /> Contact Person Phone Number @ )_97 Fax Number: <br /> Area Cotle Phone Number Area Code Fax Number <br /> Il—ContactPerson Business Email Address: -,�Q LGm <br /> 11.Le' gal Busmese Owner(not Property oy <br /> Owner Address: <br /> f Owner Phone Number Z <br /> i � <br /> ♦XretL-�)-1�i.�L Fax Number: rfQQd. <br /> j}� <br /> A a Cotle Phone Number Area Cotle Fax N n ber-z- <br /> [12.Standard Industrial Classification(SIC)Code for the Site: <br /> —— — (4-Digit Number) <br /> 13.Certification:)e,am rat erpenalty off l�a/�wy/th��a/t t�he�information on,his document was prepared to the best of my knowledge and <br /> belief to be true,accurate and rromplet— <br /> SIGNATURE(handwritten)_r —1 <br /> Name(print) ,II �, Date <br /> t�k.l1'�5QfA(,Qitl Phone <br /> I7TSC Forn 1358(08/16) _ <br /> Page 3 of 3 <br /> k. <br /> Lydia Baker, REHS Page 3 of 3 <br />