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0 <br />State of California - California Environmental Agency Department of Toxics Substances Control <br />Linda S. Adams <br />Secretary for Certified Appliance Recycler Application <br />Environmental Protection <br />Please submit to: <br />Department of Toxic Substances Control <br />Attn: Consumer Products Section- CAR application <br />1001 T' Street, 11th Floor <br />P.O. Box 806 <br />Sacramento, California 95812-0806 <br />Or <br />CAR@dtsc.ca.gov <br />Before you may remove "materials that require special handling" (MRSH) from a major appliance, you must be <br />approved as a Certified Appliance Recycler, pursuant to Health and Safety Code Section 25211 et seq (AB 1447, <br />2007). You must also provide evidence of your CAR status to scrap metal facility. <br />Once a certificate is issued, DTSC will notify the certified uniform program agency (CUPA) in your jurisdiction <br />responsible for inspecting the certified appliance recycling facility. <br />Certificates issued will be valid for three years. Once your certification has expired, you are no longer a Certified <br />Appliance Recycler. In order to continue operating as a CAR, you must renew your certification before the expiration <br />date. <br />Please note: Any changes to the information provided on the Certified Appliance Recycler Application must be <br />submitted to DTSC in order for the certification to be valid. <br />El Renewal o CAR Number. �" tS ` Please note: Entire application must be completed. <br />1. Business Information fesf/// O <br />Business name under which the applicant operates: LIS r1 e 1 / 11 <br />Physical Address: o2 2c;IJ � `l/ 7rlal 16on.le_ C� � <br />Mailing Address: / /' <br />Business Phone Number: P20/Q) %%`1 - ,17d/�% Business Owner Name: ��/Ce n/AA, a -Ci <br />Owner Address: r/0 <br />Owner Phone Number: (70a );00 -7UDD Email Address (if available): ¢fCf �GrJ/lGi ��� rCT/✓I///%.�Jq <br />2.) Hazardous Waste generator identification number: C14-1�1 po��� <br />3.) Is your organization required to obtain a storm water permit? (4 Yes ❑ No <br />4.) Is your organization required to file a hazardous materials business plan? 9 Yes ❑ No <br />5.) Tax identification number, assigned by the Franchise Tax Board: _ - <br />6.) Attach a copy of a business license to this application. <br />7.) If applicable, attach a copy of conditional use permits issued by the appropriate city or county to this application. <br />DTSC 1428 (11104/2010) <br />