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State of California-California Environmental P* '-ction Agency -)apartment of Toxic Substances Control-GISS ,.o-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_.cjov 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: W Generator ❑Transporter Reason for new number: A. ❑ Never had a number B. M Business moved C. ❑ Legal owner of business changed If yourbusiness generates greater than 100 kg of RCRA hazardous waste permonth, call(415)495-8895 for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER fe"n tru tions.) For existing ID number: C A L_ _ _ 1.Z g Z_Q g 2. 1 am updating the mailing address and/or contact information only. NOV 13 2014 ❑ 3. 1 am inactivating this ID Number. ❑ 4. I am reactivating this ID Number. ENVIRONMENTAL HEALTH ❑ 5. 1 am changing the business name only,no ownership change. DEPARTMENT �r (See instructions.) 6. Site/Facility/Business Name(include DBA): J4: � f�'�r?71.c�It_-(�.. 7. Site Location: Street ✓ LC K TLZ 1. %Jdn/.� VQf� Uwx ufn city State Zip bounty 8. (a) Federal Employer ID Number (b)Board of Equalization Fee Account Number G' ((bn)is only required from generators of greater than 5 tons per calendar year.) 9. Mailing Address: J�A-rvlP (See instructions.) Street City State Zip C C I/5��e (See instructions.) 10. Site Contact Person: U" f� First Name Last Name Contact Person Address: Street City - State Zip Contact Person Phone Number: A Fax Number: Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: Preferred Primary Communication: ❑ Mail ❑ Email p p 11. Legal Business Owner(not property owner): L,�M1--�I C_ � (See instructions.) Y7.�'G-rte , (( Name r Owner Address: Stree City State Zip Owner Phone Number. ( Fax Number: 06c7 ) c. (e";L Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification (SIC)Code for the Site: _ (4-Digit Number) (See instructions.) 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and belie/to be, true, accurate and complete. SIGNATURE DATE NAME(print) TITLE - PHONE DTSC Form 1358(10/12)