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State of California - California Environmental Protection Agency Department of Toxic Substances Control - GISS P.O. Box 806, Sacramento, CA 95812-0806 Reset Fo M7 Print 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 ww4v.hvts.dtsc.ca. ov and click on Re orts. NEW NUMBER REQUESTS Check all that apply. (See instructions.) ©''1. I am applying for anew 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 vour business Generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA 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 instructions.) 6. Site/Facility/Business Name (Include DBA): rti L 7. Site Location: °iStreet - �'11 c_s:C)1 i (� t'1 " h "?Z.Li"� 7 City State Zip County 8. (a) Federal Employer ID Number � Board of Equalization Fee Account Number __ ((b) is only required from generators of greater than 5 tons per calendar year.) (See instructions.) 9. Mailing Address: -6 � ,n; � -`� � ► '2 - Street f��a City State Zip (See instructions.) 10. Site Contact Person: 1 t"1 My N C may"~ First Name Last Name Contact Person Address: '� ">`� `N evV_ '-I Str- eet -17 s.Z City State Zip Contact Person Phone Number: ( �`i) --75 0- _ Fax Number: '( �`I) 4 t°-4 - 4' Area Code Phone Number Area Code Fax Number,,_/ Contact Person Business Email Address: �� fASi CIAS �,' �� • ' " Preferred Primary Communication: LVIMail -ail (See instructions.) 11. Legal Business Owner (not property owner): t� 4 t� Ps' C��✓`� ��, a Name Owner Address: `2 �` a cry i �12 i '-"C-> Street City State Zip Owner Phone Number. (2 t7�1) 4a L - 7 Fax Number: (I Vii) Li L', Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification (SIC) Code for the Site: _ 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true, accurate and complete. SIGNATURE DATE Gam.• 2�a - ? �i"2.. NAME (print) %l F% 1 A y� TITLE DVJ'i-1 ti PHONE I ��- 1358 (04/12)