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EPA ID NUMBER��.r 6�J� Pap'2 of <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME (DBA) <br /> STREET 1AA L�floQeSS 57�� P1+D77f .S/f�0 <br /> L.�35 <br /> CITY SroG K/Z J STATECA ZIP 9SZJ7 <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON 7)AMry i SA PHONE NUMBER( ZU5)_IY-_"0 <br /> (First 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: 7384Photofiniehin2lab 3671 Printed circuit boards <br /> First: 7j b`� 1113 Second: <br /> IV. PRIOR PERMIT STATUS: Check yes or no to each question: <br /> YES NO <br /> ❑ ❑ 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 /> � status for any of these treatment units? <br /> ElIYJ/ 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 /> tLl( 4. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br /> i are now notifying for at this location? <br /> ❑ 5. 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 nothing as conditionally exempt. <br /> YES NO <br /> ❑ Within the last three years, has this facility been the subject of any convictions,judgments, settlements, or find <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 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 />