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MAILING ADDRESS, IF DIEET:RENTe <br /> COMPANY NAME (DBA) <br /> STREET <br /> CITY STATE ZIP <br /> COUNTRY <br /> (orJy compleu if nor USA) <br /> CONTACT PERSON PHONE NUMBER( ) <br /> (F.m Name) (Vv Name) <br /> RI. TYPE OF CONIPAN ': STANDARD INDI'STRIAL CLASSIFICATION (SIC) CODE: <br /> Use tither one or rwo SIC codes (a jour digit number) that best describe your company's products, services, or tndusrrnal am vin <br /> Example: 7384 Photortnuhinr Lab 3672 Pnnted circuit boards <br /> First: Ur q Second: <br /> rV. 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 /> ❑ eE� 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or mtenm <br /> status for any of these treatment units? <br /> 3. Do ,you oo.G 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 /> ❑ 0. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br /> y are now notifying for at this location? <br /> ❑ �q <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 fnoen generators only notifying as co dWonally exempt. <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 un)e�i, <br /> it wit not corrected and became a final order.) <br /> ❑ If you answered Yes, check this Mix and attach a listing of convictions,judgments, setllernems, or orders and a copv <br /> of the cover sheet from each document. (See the Instructions for more information) <br /> DTSC 1772 (1/93) Page 2 <br />