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EPA ID NUMBER CAL00Page 2 of 6 <br /> MAILING ADDRESS, TF DI UUNC: <br /> COMPANY NAME (DBA) Same as location <br /> STREET <br /> CITY \ STATE _ ZIP <br /> COUNTRY (may,o Vt.a it not USN <br /> CONTACT PERSON PHONE NUMBER(_ <br /> (Firs Nurse) Na Name) <br /> y.t <br /> ID. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE: <br /> Use either one or two SFr cra3c (a four digit nwnber) ihat bast describe your company's produds, servlet, or Industrial atxlvtryti . <br /> ExampleZ $4 - L Prirhted'circult boards <br /> f <br /> Fes: 4911 Electrical Services Second. <br /> IV. PRIOR PERMIT STATUS: Check yes or no to each question: <br /> YES NO <br /> 19 ❑ 1. Did you file a PBR Notice 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 interim <br /> ttqq status for any of these treatment units? <br /> ❑ tint 3. Do you now have or have you ever held a state or federal full permit or interim status for say other <br /> rtpptI hanrdous waste activities at this location? <br /> [3 11 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? <br /> ❑ ® S. Has this location ever been, inspected by the state or any local agency as a hazardous waste genamu ? <br /> V. PRIOR ENFORCEMENT HISTORY: Not required front generators only wd,&ng•as oOr-d4101%a1ly ernnpt• <br /> YES NO <br /> ❑ ® Within the last three years. has this facility been the subject of any convictions,judgments, settlements, or final <br /> orders resulting from an action by any local, state, or federal environmental, hazardous waste. or public health <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 Lad a copy <br /> of the cover sheet from each document. (See the Instructions for more information) <br /> DTSC 1772 (1/93) Page 2 <br />