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State of California — California Environmental Protection Agency Department of Toxic Substances Control - GISS P.O. Box 806, Sacramento, CA 95812-0806 Reset Form Print CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line -by-line instructions carefully. I o check on the status of your request go to www.hwts.dtsc.ca.gov and click on Reports NEW NUMBER REQUESTS Check all that apply. (See instructions.) 1. I am applying for a new perma nt California ID number as a hazardous waste: Generator ❑Transporter Reason for new number: A. ever had a number B. ❑ Business moved C. ❑ Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBERt s. For existing ID number: C A ❑ 2. 1 am updating the mailing address and/or contact information only. JAN 2 U 2011 ❑ 3. 1 am inactivating this ID Number. ❑ 4. 1 am reactivating this ID Number. ENVIRONMENTAL HEALTH ❑ 5. 1 am changing the business name only, no ownership change. PERMIT/SERVICES (See instructions.) 6. Site/Facility/Business Name (Include DBA): "'o i D Q� i btsl� PQ�C_ SoC2 C= P►f'Cr 7. Site Location: _942— -_511 Yj0<410 Z\,J A Street C7 k €QC' nJ City State Zip County 8. (a) Federal Employer ID Number S —02i Ei 0 g4- Board of Equalization Fee Account Number ((b) is only required from generators of greater than 5 tons per calendar year.) 9. Mailing Address: E'A 2— �= T 6A <_srpC_VQ(._j A, (See instructions.) Street 21Pe C,A��(�; City State Zip 10. Site Contact Person: " a e \c_. rE_eGtQ S C %,1 (See instructions.) First Name Last Name Contact Person Address: 2 �sG (aft ► 1--Y�s'� Street fr JAI-1 t_k (?—U 1P 6A City State Zip Contact Person Phone Number: (Z13) ' bs s-- 41-)oo Fax Number: 2Qa) 9fu's w .4 (_�01"e-) Area Code Phone Number Area Code Fax Number Contact Person Business Email Address:_M Preferred Primary Communication: ElMail ❑ Email (See instructions.) 11. Legal Business Owner (not property owner): `T> i Ya ('-ka 0 PC 1 —'Ds Name Owner Address: ® PJ . O L— t fir' IF, ® („ 50'vj Street City State Zip _ Owner Phone Number: ( 73) 2Z� ,400 °S Fax Number: (513)Z. — 4�� Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification (SIC) Code for the Site: 2 li (4 -Digit Number) (See instructions.) 13. Certification: I ce under penalty f law that the information on this document was prepared to the best of my knowledge and belief to be, true aV curate and let SIGNATURE r DATE 1� ✓ 10 v b NAME (print) J� -7 F_tm � �,�Q,�h�ti� TITLE ,/LO A PHONE DTSC Form 1358 (6/08)