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0 0 <br /> Stale of California-California Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> hs ` ,�, P.O.Box 805,Sacramento,CA 95812-0806 <br /> Reset For,;.,; P�int. > <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly print in ink. Please review the line-by-line instructions carefully. <br /> To check on the status of your request,go towww.hwts.dtsc.ca, ov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator Transporter <br /> Reason for new number. A. Q Never had a number B. ❑ Business moved C. E] 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 EXISTINGGID NUMBER ? (See instructions.) <br /> For existing ID number. C A -a � ,Q L L/ � -1- —,</— e1- <br /> 2. I am updating the mailing address and/or contact information only. <br /> C] 3. I am inactivating this ID Number. <br /> 4. I am reactivating this ID Number. <br /> 5. 1 am changing the business name only, no ownership change. <br /> �� (See instructions.) <br /> 6. Site/Facility/Business Name(include DBA): &5+ 1PK C J LGC <br /> 7. Site Location: J0.3 50 Soul// T,P.4c rl Bbft EuA�b <br /> i 5 .4c y C'9 9x376 & 'T4gQY'6,.Z <br /> City / State Zip County <br /> 8.(a)Federal Employer ID Number (b) Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> TT�� (See instructions.) <br /> 9. Mailing Address: FD .&ox l 97 <br /> Street <br /> PC EA a troy e.4 9`/.566 <br /> ity Stale Zip <br /> (See instructions.) <br /> 10. Site Contact Person: '&S'rz% 4Zb6A.//4rYS <br /> First Name Last Name <br /> Contact Person Address: Po Zo)( 627 16 Y 57.4•V.CEY -ML!•Cf'y4zb <br /> rq�t l <br /> StrCF.4sA„ro..� G.9 <br /> City State Zip <br /> s <br /> .Contact Person Phone Number. (/.�J) �'.2G-�.z6� Fax Number. (7� '�6.2— 5J 7Z <br /> Area Code Phone Number Area Cade Fax Number <br /> ,�I$fRTi9,/91LFNNwV3E✓ <br /> Contact Person Business Email Address: CCW(5:ez'1F)r . COM Preferred Primary Communication: ] Mail VEmail <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): CA5i7L:x <br /> 4 �7 me <br /> Owner Address: sIOo �j&.bii✓Na ,6ryxe 1,e /Y 64 J>ez 11D 'W-des CA. 94'7b-.2 <br /> Street City State 9., 7 iD - <br /> Owner Phone Number. (ML 9f'/'�FSOU Fax Number..(�� 7 <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification (SIC)Code for the Site: Z _�/ (4-Digit Number) (See instructions.) <br /> 13. Certification: enalty of law that the information on this document was prepared to the best of my knowledge and <br /> bellef to be,true, cc rate mpal� <br /> SIGNATURE ��// G DATE <br /> NAME(print) Z,34E7 ljzbe'waYJ6N TITLE PHONE /•2s�S/�• -��� <br /> ,Nsl.✓AGE)e <br /> DTSC Form 1358(6108) <br />