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Stato of California—California Environmental Protection Agency Department of Toxic Substances Control-GISS Reset Form P.O.Box 606,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 re uest,go to www.hwts.dtsc.ca.gov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) 4_1- _1. I am applying for a new permanent California ID number as a hazardous wasted Generator ❑Transporter Reason for new number: A. ever hada number B. ElBusiness moved C. E')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 EXISTINGID NUMBER (See instructions.) For existing ID number: C A n 2. 1 am updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID Number. ❑ 4. 1 am reactivating thi Site/Facility/Business Name(Include DBA): C 'Cl \0 V^Ck VV-_0�✓� ✓ J 7. Site Location: S eetCfL � C + CityGtti Mate Zip County 8.(a)Federal Employer ID Number 1 1 3��G 1`S. _ Board of Equalization Fee Account Number ((b)is only required from generators of greater than 5 tons per calendar year.) , rL (See instructions.) 9. Mailing Address: 5a`�► `J V.., S�� ,L; Street `_- 0 C v4 CAS s- City State Zip (See instructions.) 10. Site Contact Person: CC eyo First Name n 1 L st Name Contact Person Address: Strr t� z: \ZJ! City State Zip Contact Person Phone Number: � Fax Number: Area Code Phone Number Area Code Fax Number U�y�0.CD V- Contact Person Business Email Address: ec -e'yo 191 Preferred Primary Communication: Mail ❑Email (See instructions.) 11. Legal Business Owner(not property owner): �Uc� \CICU U S Owner Address: `�- �Nam � U0�k'1 _�C��C C �. �� Streex City State Zip Owner Phone Number: (o`er J)0 0�J'— I—7 S� Fax Number: (�E'�) 4 c"�f ��v f Area Code Phone Number Area Code Fax Number L L� 12. Standard Industrial Classification(SIC)Code for the Site: I ` (4-Digit Number) (See instructions.) 13. Certification: I certify a der 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. J� SIGNATURE DATE NAME(print) �CTITLE� Q Q d✓� UYxGtV4--PHONE r— —[,r-3 DTSC Form 1358(6/08)