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SEP-6-21006 01:26 FROM: TO:4683433 P.3/3 <br /> Npnrtment of Toxic Substances Control-GISS <br /> State of Califomin—caufomia Environmental Protection Agency p,p,gox 806.SaP'anlento.CA 95812-0608 <br /> imMIllylIIIIIII <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> please type or neatly print In Ink. Please review the line-by-Ilne inset tict ons carefully. <br /> To check on the status of our re Lest. oto (See instructions.) <br /> NEW NUMQU REQUEST3 Check ail that apply. <br /> 1- I am applying for a now permanent California ID number as a hazardous waste:0Generator Transporter <br /> Reason for now number A. Never had a number B. Q Business moved C. ❑Legal owner of business changed <br /> If our business enersles reate�an 100 kg of RCRA hazardous waste per month, contact US EPA for a federal 10 number- <br /> QHANr ES TO STATUS OR INFORMATION FOR AN EXISTINN (Soo instructions) <br /> For existing ID number. C A —� <br /> 0 2. 1 am updating the mailing address and/or Contact information only <br /> �] 3. 1 am inactivating this ID Number. <br /> 4 1 am reactivating this 10 Number. <br /> rl 5. 1 am changing the business name only, no ownership Change, <br /> (See Instructions.) <br /> 13. Site/Facility/Business Name(lnriude DBA): <br /> 7- Site Location: / 3 3 !�; S, ,.02,16A-A) <br /> t7/n) <br /> ZipCounty <br /> City �y 3 <br /> tateBoard of Equalization Fats Account Number <br /> 8- (a)Federal Employer 10 Number <br /> ( b)i5 onl required hem generators of greater than 5 tans per calender yearj <br /> J �^ (See instructions-) <br /> 9. Mailing Address: / 3 �✓ J � �I P�� <br /> $Ireet n �l <br /> G �rLL <br /> —C� State Tl <br /> ity (See instructions.) <br /> 10. Site Contact Person: _ <br /> First <br /> NNaame Lost Name <br /> Contact Parson Address: ��� (11Street / <br /> ( <br /> CIS r7 N state /`` zip <br /> �) C1 5:3- — Fax Number: (�1 <br /> Contact Person Phone Number: Area Code Phone Number Area Code Fax Number <br /> neo A-4 0[mail <br /> Contact Person Business Email Address:�J) �3 3 S a '� <br /> Preferred Primary communication 5dsmail <br /> �D,S� <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner)'. �"i <br /> aName D r_L <br /> Owner Address: oC L I City c�/(J State zla <br /> St <br /> Owner Phone Number: � Y(poZ—��� Fax Number: (_J <br /> Area ode Phone Numuer Area Code Fax Number <br /> 12. Standard Industrial Classiflcalion(SIC)Code for the Site: 4-Digit Number) (Seo instructions.} <br /> 13. Certification- /certify/under penalty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to b6,true,accurate and complet <br /> SIGNATURE DATE <br /> 1 a l CIJ� PHONE <br /> NAME(print) 1 T 1J TITLE <br /> DTSC Form 1358(6108) <br />