COMPLIANCE INFO PRE 2019 - Laserfiche WebLink

Home Browse Search

Stato of Califomia-California Environmental Protection Agency Department of Toxic Substances Control-GISS Reset Form P.O.Box 806,Sacramento,CA 95812-0806 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 www.hwts.dtsc.ca. ov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) 41. 1 am applying for a new permanent California ID number as a hazardous waste, Generator ❑Transporter Reason for new number: A. ever had a number B. Business moved C. Legal owner of business changed If your business generates greater t an 100 kg of RCRA hazardous waste per month,contact US EPA for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING 1D NUMBER (See instructions.) For existing I D 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 changi e(Include DBA): c 'Gl ✓O J 7. Site Location: Sa -1 �j w 15U"'Street (j4�- �JC� City tt Mate Zip County 8.(a)Federal Employer ID Number l '33356 1`S. • 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: �a`� � ��`S(�� Street Elk City State Zip (See instructions.) 10. Site Contact Person: `la c-C EtO First Name ` L st Name Contact Person Address: I al S �` `�� j" City State Zip Contact Person Phone Number. CLIfIrk y ^IS- I Fax Number: (�) y G4 iS Area Code Phone Number Area Code Fax Number U � }v- Contact Person Business Email Address: e -e yo 19 Preferred Primary Communication: Mail ❑Email (See instructions.) 11. Legal Business Owner(not property owner): ".iC�b S Nam Owner Address: 59 `�- W v k�� V�j ��1 � C� n C+'I c.�prp� Stree City State _ Zip Owner Phone Number: &cl 6' 03"- I-7S� Fax Number: '-:% L-1 C, —81 Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: L/ C (4-Digit Number) (See instructions.) 13. Certification: 1 certify uer penalty of law that the information on this document was prepared to the best of my knowledge and belief to be,true,acc d complete. I SIGNATURE QQ DATE NAME(print) TITLEt� CR J �tv��keM PHONEcJC� r�aJ -��lGj DTSC Form 1358(6108)