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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 TO STATUS 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. 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�<s 6a C1V1ta l ( .I�Jn i T\f�T` IGt11(P) 7. Site Location: Street — 71 r) CityL'((�� r State Zip Count 8.(a)Federal Empl yer IDN mber2J l,) p J Board of Equalization Fee Account Number_S.��}k 0`-��I�� 1� ((b)is only required from generators of greater than 5 tons per calendar year.) (See instructions.) 9. Mailing Address Street City fhb/ State ` Zip (See instructions.) 10. Site Contact P rson: first Name Last Name Contact Person Address: Ot L Street C- 1� W rv!� City - State �Zi/p Contact Person hone Nu ber. 4�Gl �� Fax Number: Area Code Phone Number�— Area Code Fax Number Contact Person usiness mail Address: 4a(&fC*J(Dfffnary Communication: Mail ❑Email (See instructions.) 11. Legal Business Dwner(no t property owner): ame C m Owner Address: Stree �� _ City go[s tateOwner Phone N mber: ( �" L� 2 q,�I Fax Number: r?Z�'iea Code Phone Number Code Fax Number �-t Ltt 12. Standard Indust ial Classi cation(SIC)Code for the Site: 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) ilE C)l l 'Yl �� PHONE�1 DTSC Form 1358(6/08