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EPA ID NUMBER CAD0956" 4973 Page 2 of 7 <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME (DBA) <br /> STREET <br /> CITY STATE ZIP <br /> COUNTRY <br /> (ody complete if not USA) <br /> CONTACT PERSON PHONE NUMBERL_) <br /> (Pint Name) (Last Name) — <br /> III. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE: <br /> Use either one or two SIC codes (a four digit number) that best describe your company's products, services, or industrial activity. <br /> Example. ZZ& Phorofrnishine lab �36jj Printed circuit boards <br /> First: 3672 Second: <br /> IV. PRIOR PERMIT STATUS: Check yes or no to each questiom, <br /> YES NO <br /> © ❑ I. Did you file a PBR Nqtice of Intent to Operate (DTSC Form 8462) in 1992 for this location? <br /> ❑ © 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or inter ,. <br /> status for any of these treatment units? <br /> ❑ ❑x 3. Do you now have or have you ever held a state or federal full permit or interim status for any other <br /> hazardous waste activities at this location? <br /> ❑ 4. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment You <br /> are now notifying for at this location? applied two times <br /> ❑ ❑ S. Has this location ever been Inspected by the state or any local agency as a hazardous waste generator; <br /> V. PRIOR ENFORCEMENT HISTORY: Not required from generators only notifying as conditionally et:empt. <br /> YES NO <br /> ® ❑ Within the last three years, has this facility hcen the subject of any convictions, judgments, settlements, or Cin.:! <br /> orders resulting from an action by any local, state, or tederal environmental. hazardous waste, or public heal* <br /> enforcement agency'? <br /> (For the purposes of this form, a notice of violation does not constitute an order and need not be reported unless <br /> it was not corrected and became a final order.) <br /> ® If you answered Yes, check this box and attach a listing of convictions,judgments, settlements, or orders and a copy <br /> of the cover sheet from each document. (See the Instructions for more information) <br /> DTSC 1772 (1/93) Page 2 <br />