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PERMANENT STATE ID NUMBER APPLICATION V vVV <br /> Please type or neatly print in ink. Please review the line-by-line instructions carefully. <br /> To check on the status of your request,Qo.to www.hwts.dtsc.ca.gov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> ❑ T I am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter <br /> Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261.5 <br /> subparts(c)and(d),per month, complete Form 8700-12 for an EPA(federal)ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (y ► iVj <br /> 'rz :� ' <br /> For existing ID number: C A _ <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. _', 2016 <br /> ❑ . I am inactivating this ID number. <br /> 4. 1 am reactivating this ID Number. <br /> ❑ 5. I am chan in the business name onl , no ownershi chan e. ENViR01\9^�ErdTAI_ <br /> NEP.LTH DEPA T�4E JT <br /> _ r _(See. ' ructios.) <br /> 6. Site/Facility/Business NNgame(include DBA): © <br /> 7. Site Location: �rl �/vt �� r t`" pb <br /> �� <br /> Street, n A <br /> City /� `� <br /> <br /> generators of greater than 5 tons per calendar ear.) <br /> ( ee instructions.) <br /> 9. Mailing Address: /1�1 ` <br /> Street <br /> City State Zip <br /> (See instructions.) <br /> 10. Site Contact Person: <br /> First Name Last Name <br /> Contact Person Address: <br /> Street <br /> City Shat{^ Zip <br /> Contact Person Phone Number: 10 Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Nuinber + <br /> Contact Person Business Email Address- 1ra VIA-,i <br /> Preferred Primary Communication Mail Email <br /> �,r (See instructions.) <br /> 11. Legal Business Owner(not property owner): . U 5V <br /> rst Name Last N e <br /> Owner Address: <br /> Street <br /> City ` Sated Zip <br /> �� /� - � �- Fax Number: <br /> Owner Phone Number: 7 ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> -— (See,instructions.) <br /> 12.. Standard Industrial Classification(SIC)Code for the Site: (4 Digit Number) <br /> (See instructions.) <br /> 13. Certification: I certify under penalty of law�r; <br /> e ' f ation on this document was prepared to the best of my knowledge and <br /> belief to be, true, accurate and complete. <br /> SIGNATURE DATE F7),9-1 <br /> NAME(print) F �� TITLE (�Vv 1� PHONE <br />