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• �,6r Zss ` L, ,o0 State of California–California Environmental Protection Agency Department of Toxic Substances Control-GISS P.O.Box 806,Sacramento,CA 95812-0806 CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line-by-line instructions carefully. To check on the status of your request,go to www.hwts.dtsc.ca. ov and click on Reports. NEW NUMBER REQUESTS Check all that apply. , (See instructions.) 1. 1 am applying for a new permanent California ID number as a hazardous waste: K Generator ❑Transporter Reason for new number: A.)V Never 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,call(415)495-8895 for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) For existing ID number. C A _ _ _ _ _ _ _ _ — ❑ 2. 1 am updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID Number. ❑ 4. 1 am reactivating this ID Number. ❑ 5. 1 am changing the business name only, no ownership change. (See instruct ons.) 6. Site/Facility/Business Name(Include DBA): 7. Site Location: y,��262(f A& Street s Pvmr On Cif qL City State Zip County 8.(a)Federal Employer ID Number �)L� (b)Board of Equalization Fee Account Number ((b)is only required from generators of greater than 5 tons per calendar year.) a/0q PSt E/ t �IGI %{1/r� (See instructions.) 9. Mailing Address: Strep�OCry'1 5� c City State Zip (See instructions.) 10. Site Contact Person: First Name / Last Name Contact Person Address: �d� N UCi/l 7,( /tl/�' — s4Ce U� CAL Ciq State '2 ip Contact Person Phone Number: t 22j1 �� _ Fax Number: (_) Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: � /7 L ferred Primary Communication: pk Mail ❑ Email //I . (See instructions.) 11. Legal Business Owner(not property owner): 4 u t � >F &Ce2C/ men Owner Address: '�)61' J-C!- �_("r //1/P /!� 0 2& �`>r�lzs ' Street City State p Owner Phone Number: ( 70Fax Number. (� Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: 13_ (4-Digit Number) (See instructions.) 13. Certification: 1 c rtify under penalty of law than 1e information on this document was prepared to the best of my knowledge and belief to be,truaccurate and complete. SIGNATURE DATE C) 6 �T2aJ-3 NAME(print) f/� F�� rural TITLELI!/UP_� PHONE C� DTSC Form 1358(10/12)