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State of California — California Environmental Protection Agency Department of Toxic Substances Control - HWMP <br /> P. O. Box 806, Sacramento, CA 95812-0806 <br /> PERMANENT STATE ID NUMBER APPLICATION <br /> Please type or neatly print in ink. Please review the line-by-line instructions carefully. <br /> To check on the status of your request, go to www .hwts .dtsc.ca .gov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> ❑ 1 . 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter <br /> Reason for new number: A. ❑ Never had a number B . ❑ Business moved C. ❑ Legal-owner of business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261 . 5 <br /> subparts (c) and (d), per month, complete Form 8700- 12 for an EPA (federal) ID, number. ; <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) <br /> For existing ID number: C A [_.- a 9 c) 3 1�K � <br /> ❑ 2 . lam updating the mailing address and/or contact information only. <br /> ❑ 3 . 1 am inactivating this ID number. <br /> 3'4 . I am reactivating this ID Number. <br /> ❑ 5 . 1 am changing the business name only, no ownership change . <br /> (See instructions.) <br /> 6 . Site/Facility/Business Name ( Include DBA) : 1 ULo <br /> 7 , Site Location: L "1114ew tic CW4Xk •"� - <br /> Street <br /> kn r <br /> City State Zip County <br /> 8 . (a) Federal Employer ID Number '1t)l q 4 24 (b) Board of Equalization Fee Account Number <br /> (b) is only required from generators of greater than 5 tons per calendar ear. <br /> (See instructions.) <br /> 9. Mailing Address: io L <br /> Street <br /> i. s_ r C R C\ V3 <br /> City State Zip <br /> n (See instructions.) <br /> 10. Site Contact Person : n _ a.. <br /> First Name Last Name <br /> Contact Person Address: <br /> Street <br /> UWA `( 0`3 � <br /> City o State Zip <br /> Contact Person Phone Number: 2( 1pol - cX07� Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: q o i tYl <br /> Preferred Primary Communication : ❑ Mail O] Email <br /> (See instructions.) <br /> 11 . Legal Business Owner (not property owner): �j C� �� ' <br /> First Nam Last Name <br /> Owner Address: <br /> Street tt <br /> L� VN% Z� �P <br /> City 2cp� _ � � t 22 State zip <br /> Owner Phone Number: ( ) Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> (S <br /> 4instructions.) <br /> 12, Standard Industrial Classification (SIC) Code for the Site : S 1 (4-Digit Number) <br /> (See instructions.) <br /> 13. Certification : t certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be, true, 2curate and complete. <br /> SIGNATURE (� c DATE 2Z Z3 I <br /> NAME ( print) `t—o`n J Q`r�C • A 0,P Oft. TITLE fT)p n PHONE 2�`� :i <br /> DTSC 1358 (5/29115) <br /> VIOLATION - 101 <br />