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State of California-California Environmental Protection Agency Department of Toxic Substances Control -HWMP P.O.Box 806,Sacramento,CA 95812-0806 PERMANENT STATE 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 wmv,fivits dtsc.ca.aov and click on Reports. NEW NUMBER REQUESTS Check all that appy. (See instructions.) ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter Reason for new number: A. ❑ 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 other than those hazardous waste listed in 40 CFR 261.5 subparts(c)and(d),per month, complete Form 8700-12 for an EPA(federal)ID number. - 1 CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See-in For existing ID number: C A L /) GG .� - JUN 2 2 2016 ❑ 2. 1 am updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID number. r+�?e��►b�= gj 4. 1 am reactivating this ID Number. ❑ 5. 1 am changing the business name only, no ownership change. (See instructions.) 6. Site/Fadlity/Business Name(Include DBA): e ee f S 7. Site Location: ((G t "o" 1'q- L+• L street`L �/ Cityo �` Stale Zip County (b)Board of Equalization Fee Account Number is only required from generators of greater than 5 tons per calendar yearl (See instructions.) 9. Mailing Address: 54Mt q et/L¢ street City state Zip (See instructions.) 10. Site Contact Person: ra �p i Frrst Name Last Name Contact Person Address: 54 G1U 4li o'v� Street city State Zip Contact Person Phone Number: (,7;A*;T-31-L8 Fax Number. ( ) Area Code Phone Number Area Code Fax N'}mber Contact Person Business Email Address: G'h o u'LO-�f Preferred Primary Communication: ❑ Mail Email � (Sea instructions.) 11. Legal Business Owner(not propeity owner): 64r f t v - k Ora First Name Last Name Owner Address: !k Street City State Zip Owner Phone Number. 120'8 4 L_7-'?T.71? Fax Number: ( ) Area Code Phone Number Area Code Fax Number 7 (See instructons.) 12. Standard Industrial Classification(SIC)Code for the Site: l Z 1 Z.- (4-Digit Number) (See instructions.) 13. Certification: I certify under penal 'nform tion on this document was prepared to the best of my knowledge and belief to be, true, accurst plate. SIGNATURE n o Cliff DATE 6 (''' It NAME(print) l�� 1'6(0v4j5;1 TITLE 6Wr4C/ PHONE ' YI - `{35( DTSC 1358(5129/15)