Laserfiche WebLink
State of California-wealth and Yelfere Agency Department of Hlalth se .'Ces <br /> t <br /> DISCLOSURE STATEMENT toxic Substances Controt 0'. s : <br /> I . Chect the categories below which apply to the applicant. 714/744 P Street, P.O. sox 942732 <br /> —Z�Nazardoua waste Neuter Registration Sacramento, CA 94234-7320 <br /> Hazardous Waste Facility Permit <br /> Contract Competitors <br /> 11. a. Mame of Applicant CItT� � AJ r«` AJ <br /> b. Previous xame(s) N <br /> City tete Zip Code <br /> c. Business Address ��7 'y Vl �I dN -�T•t �tV <br /> 5 <br /> ;' -_ •.. - - - it StateZipCode <br /> d. Previous Business Addresses) <br /> (within the last three years, use continuation sheet, if necessary) <br /> e. Organization of eusiness Concern/: (Check one) <br /> _sole proprietorship _- corporation partnership _joint venture (i.e., trust or association) <br /> f. EPA 10 Number (if applicable) 2P ti N1 pin <br /> g. Neuter Registration Number (if applicable) 1 <br /> 111. List all officers, directors, or partners of fire shown in item Il.a.: <br /> R(�-I«ti T;tle �5( -�nT— <br /> a. Name ��/�,` - <br /> Business Address .VIOrV ty�_State" t� f 'C Zip <br /> Social Security No. N <br /> Previous Names • 4 <br /> DNS 8430 (2/88) Page 1 <br />