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.lo\ State of California - California nvironme,aal Protection Agency Department of Toxic Substances Control - GISS Reset F rmPrint P.O. Box 806, Sacramento, CA 95812-0806 C LIFO NIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line -by-line instructions carefully. o check on the status of your request, go to www.hwts.dtsc.ca.gov and click on Reports. NEW NUMBER R1EQUESTS Check all that apply. (See instructions.) 1. 1 am apply i g for a n w permanent California ID number as a hazardous waste: E] Generator Transporter Reason for n numbe . A. El Never had a number B. 0 Business moved C. [] Legal owner of business changed If your business g nerates eater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. CHANGES TORTATI IS 00 INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) For existing 10 nu ber: A C— L L 7 Z ❑ 2. lam updati g the mai ing address and/or contact information only. 3. lam inactiv ting this t Number. P�_4. lam reactiv ting this I D Number. C] 5. lam changi g the bu iness name only, no ownership change. 1 ,( (See instructions.) 6. Site/Facility/Bu iness Name (Include DBA): 1� SU� C1V1ta l (.I�Jn i T \f�T` IGt11(P) 7. Site Location: Street — �/ City— r State Zip Count 8. (a) Federal Empl Dyer IDN mber2J l.) p J Board of Equalization Fee Account Number S. ((b) is only required from generators of greater than 5 tons per calendar year.) 10. Site Contact Contact PersonlAddress: m itw m Y_Aeod' oz (See instructions.) 'First j Last Name Contact Person hone Nu ber. 4 �Gl S� Fax Number: ( `� tl�Y2�6I Area Code Phone Number �— Area Code Fax Number Contact Person usiness Email Address: 4a (&**j(VfVnary Communication: Mail ❑ Email (See instructions.) 11. Legal Business wner (nc property owner): ame C Owner Address: Stree �_ City State Owner Phone N tuber: ( �" L� �� f - 2 �� I Fax Number: r? Z�'iy; A ea Code Phone Number Area Code Fax Number 12. Standard Indust ial Classil cation (SIC) Code for the Site: l'-0�-t Ltt O 1 (4 -Digit Number) (See instructions.) 13. Certification: I c rtify and penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true accurate and complete. 7 1 SIGNATURE , Z' tel. DATE NAME (print)�6(1,14ft16PnOL_&�POE C2 PHONE�1 k (See instructions.) 9. Mailing Address Street � , j �b( 1 ) City State Zip 10. Site Contact Contact PersonlAddress: m itw m Y_Aeod' oz (See instructions.) 'First j Last Name Contact Person hone Nu ber. 4 �Gl S� Fax Number: ( `� tl�Y2�6I Area Code Phone Number �— Area Code Fax Number Contact Person usiness Email Address: 4a (&**j(VfVnary Communication: Mail ❑ Email (See instructions.) 11. Legal Business wner (nc property owner): ame C Owner Address: Stree �_ City State Owner Phone N tuber: ( �" L� �� f - 2 �� I Fax Number: r? Z�'iy; A ea Code Phone Number Area Code Fax Number 12. Standard Indust ial Classil cation (SIC) Code for the Site: l'-0�-t Ltt O 1 (4 -Digit Number) (See instructions.) 13. Certification: I c rtify and penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true accurate and complete. 7 1 SIGNATURE , Z' tel. DATE NAME (print)�6(1,14ft16PnOL_&�POE C2 PHONE�1 k