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State of California-California Environmental Protection Agency Department of Toxic Substances Control-GISS Iii- P.O.Box 806,Sacramento,CA 95812-0806 eS oNm: P 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.gov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) P"I '. 1 am applying for a new permanent California ID number as a hazardous waste: ® Generator El Transporter Reason for new number. A. H'Flever had a number B. El Business moved C. E] Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste per month,contact US EPA for a federal 1D 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. j ❑ 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): 17A ST N C-21 11 16 7. Site Location: r3gg tpSe V %A e A!,) Street ✓`1O V\k Joag 0j hi City )is only required from generators of greater than 5 tons per calendar year) (See instructions.) 9. Mailing Address: 1399 6- VoSecy\,e- Y\\),e- Street HA�t��a C A City State Zip (See instructions.) ` 10. Site Contact Person: i KAA M 00 Mx A First Name Last Name Contact Person Address: 1399 `Jr�S�vi�k Street ( tA ��33 City State LA Contact Person Phone Number. (SSQ) 213_ C)�Sit Fax Number: (5Tq) -t 7.3— i-lQ:1[� Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: v\ LOreferred Primary Communication:0M.il ❑Email (See instructions.) 11. Legal Business Owner(not property owner): Vf M A VI 0 o HAA i—\)i rt A4 Vt7KJPA Name Owner Address: 1399 C- `l U S e �� h P Lha 4 k � lei 01 S 3 3 6 StreeL. City State Zip Owner Phone Number: ( 213- 04SA Fax Number: (�5�1) L- a 3 - LAY -T'D Area Code Phone Number Area Code Fax Number t' 12. Standard Industrial Classification(SIC)Code for the Site: (4-Digit Number) (See instructions.) 13. Certification: I certi under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true, a curate and complete. SIGNATURE DATE NAME(print) J1 �t141MJy��ri TITLE 0LA)L,\f PHONE DTSC Form 1358(6/08)