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State of California—California Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> P,O.Box 806,Sacramento,CA 95812-0806 <br /> Reset Formm =<Print <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly print in ink. Please review the line-by-tine instructions carefully. <br /> To check on the status of your request.go to www.hwts.dtsc.ca. ov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply, (See instructions.) <br /> 1. I 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 per month, contact US EPA for a federal ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number: C /4 <br /> 2. 1 am-updating the mailing address andlor contact information only. <br /> i <br /> [] 3. 1 am inactivating this ID Number, <br /> ❑ 4. 1 am reactivating this ID Number. s <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> I <br /> (See instructions.) <br /> 6. Site/Facility/Business Name(Include DBA): ` 41 Y3 'It I h IVf ir- 0, Lk 10 ' <br /> 7. Site Location: ._'�cr)c t1 - ylq S!�o n P10 t _ <br /> -StreetVCA <br /> City Sta a Zip '1 County <br /> 8.(a)Federal Employer ID Number Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> �O (See instructions.) <br /> 9. Mailing Address: C�C� _ <br /> Street <br /> = <br /> City State Zip <br /> K f G � 4 iii I Ci C C> (See instructions.) <br /> 10. Site Contact Person: <br /> First Name ast Name <br /> Contact Person Address: F. :• 5 Co <br /> Street <br /> i <br /> City (� tState Zip <br /> Contact Person Phone Number: ( 3�' 7 (7 Fax Number. U <br /> s _ Area Code— Phone Number- Area Code _.t Fax Number <br /> Contact Person Business Email Address: Preferred Primary Communication:.0,1Mail ❑Email I <br /> r !!r,,� f (See instructions.) <br /> 11. Legal Business Owner(not property owner): 9 �Y �W� ^ _Ac <br /> Name 1pr` <br /> Owner Address: 3. A T a (•/ <br /> Street S T i 9(09 City ( tate Zip <br /> Owner Phone Number. J UJ j Fax Number. <br /> kQ <br /> Area Cede Phone Number ' Area Code Fax Number <br /> — <br /> 12. Standard Industrial Classification(SIC)Code for the Site: ! 4 a: (4-Digit Number) (See instructions.) <br /> 13. Certification: I 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,accurate complete_ <br /> SIGNATURE DATE__ l J <br /> J�� G' <br /> NAME(print) G 1 TITLE ►tit 1 ��rt� PHONE O '• 3 ` 5 7 <br /> DTSC Form 1358(6108) <br /> i <br />