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State oi•Califomia-Califomia Environmental� -dcfion Agency aartment of Toxic Substances Control-GISS P.p.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.hw s.d sc.ca. ov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instnictions.) ® 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. Q Legal owner of business changed If your business generates greater than 900 kg of RCRA hazardous waste per month, contact U5 EPA for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) For existing ID number: C A -L --4L> b CJ 2 -I-- 1— Z n 2. 1 am updating the mailing address and/or contact information only. [] 3. 1 am inactivating this ID Number. X3 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 DSA): ��}l.f F�N t 0-1 G�t�S'�A TJ D N L Lcc 7. Site Location: o�`I Z O S I U N E P Street CA S 3 Glty --r State zip County S- (a) Federal Employer ID (b)Board of Equalization Pee Account Number ((b)is only required from generators of greater than 5 tons per calendar year.) 9. Mailing Address: �/ Z0 WC 5 j G RQF) C4 j/ 1�i w j- /�w (See instructions.) Street City State Zip 10. Site Contact Person: f�0 I`t iV kil as (See instructions.) First Name Last Name Contact Person Address: L69q"Tp't C711�L F C- Street 9-5 3 City State Zip Contact Person Phone Number: ( ). 0_�'J"33 P Fax Number. Area Code Phone Number Area Code Fax Number Contact Person Business Email Address:gvsa i A)l AflC.CDM Preferred Primary Communication:0Mail QEmall �U f r� � (See instructions.) 11. Legal Business Owner(not property owner): J �//iV rln Name Owner Address: Street City State Zio Owner Phone Number. CZ191 ) 6L{d- 70$Z- Fax Number. ( 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 belief to be, true, accurate and complete. - SIGNATURE �' � �1y^� `�'�! DATE d NAME(print) QSrIA Mr�H� TITLE Z�n��fl P ONE ( 2 8�"1 3 DTSC Pomt 1358(6108)