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6C99'�N Wd05�6 �zoz 'Z 'ady aiuil pania�a� <br />e �tsiteror Galffornla — Callfornla Environmental Protection Agency Department of Toxic substances Control <br />OfFlce of Environmental tnformetion Mana®ement <br />PERIVIA,NENT STAT�,ID NUIVI<3ER ApPL.ICATIt7N <br />pl®ase lupe or print !e Ib! in Ink. <br />NEW NUMBER R�QUt:STS Check ell that apply <br />[� 1. I em applying for a neve permanent California ID number as a hazardous waste: Q Generator ❑Transporter • , <br />Reason for a new number: A. � Never had a number t3. ❑Business moved C. ❑Legal owner of business changed <br />subnaM u(cl) a d�d) p®rmonthapr ase comp�e Form 8700-92 f ra foderaltEPA ID �mber.azardous waste listed In 90 CPR 267.5 <br />For existing ID number: C A_ ��- �, �. • • -- .��G^�/, <br />❑ 2, I am updating the mailing address andlor contact information only. Ls., „i ,P-� �� � ��j �� �' <br />❑ 3. 1 am Inactivating this ID number. %!� <br />�4, I am reactivating this iD number. Reason (please select one): A. � Verification Quesllonnaire' B. p Other <br />❑ 5. I am changing the business name only, no ownership change. <br />6. Siteli"acilltyleusiness Name (Include DBA): <br />7. Site Location: <br />City <br />8, (a) Federal Employer Ip N <br />9. Mailing Address: <br />10. Site Contact person: <br />.r. <br />—���� Board of Equalization Fee Account <br /> son/v tocrutred ircrtr generators of gr. <br />Contact person Addnass: -_,.. � <br />street <br />county <br />than 5 tons <br />uvea <br />Contact Person phone Number: �► �) .� "����=-- Fax Number: �L11 � ' �–�+ �� - — <br />"re� Code Phono Number Area Gado ax Number <br />17. Legal [3uelness OWner (not prop,Ariy owner): <br />e - T.: ��� t �...� <br />�12. Standard Industrial Classification <br />13. Cerrtifilcation: I ce111fy under <br />bviief to De true, accurat� <br />SIGNATURE <br />Name .(print} <br />Code for the Site: <br />of la that the Information an this document oras prepared to the best of my know)®dge and <br />ale r� J <br />pate ��� /��- � 4 <br />Title ��-1.�10�•�__ Phone �,a:%c�,: ��'�` "'�� <br />page 3 of 3 <br />LO/80 3J'dd 3N(ll'8�}i'db9�Nb'�1S3�Vi h8988Lt�60Z ���d99 �80 �ZOZ/ZO/h0 <br />