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209 832 4259 ('^ ^6:39 p.m. 05-05-2010 8/14 <br /> State of California-California Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> P.O.Box 806,Sacramento,CA 95812-0806 <br /> esef Forrrr Print <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <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,go to www hwts.dtsc.ca. ov and click on Re orts. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> [] 1. I am applying for a new permanent California ID number as a hazardous waste: [] Generator nTransporter <br /> Reason for new number: A. n Never had a number B. E] Business moved C. [] Legal owner of business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number: C A — <br /> C] 2. 1 am updating the mailing address and/or contact information only. <br /> 3. 1 am inactivating this ID Number. <br /> 4. 1 am reactivating this ID Number. <br /> E] 5. 1 am changing the business name only, no ownership change. <br /> (See instructions.) <br /> 6. Site/Facility/Business Name(Include DBA): C.-- <br /> ZZ 7 <br /> kJ <br /> 7. Site Location: Street , <br /> `./ L .. �( _.„o'A tr%ts..(. Jac. <br /> City State Zip County <br /> 8. (a)Federal Employer ID Number g ~� (�bs only requi)Board of redEqualization <br /> ge generatorsFee <br /> of <br /> of greater unt nthan 5 tons pef cal ndar year.) <br /> ( ber <br /> (b)is <br /> instructions.) <br /> 9. Mailing Address: °2 1 l '0�l � A2.l JC <br /> Street <br /> City <br /> State Zip <br /> (See instructions.) <br /> 10. Site Contact Person: ` f' `'" l A r <br /> first Name Last Name <br /> Contact Person Address: <br /> Street <br /> Zip <br /> City f State <br /> Contact Person Phone Number: ( lE`� ) Fax Number: X061) 3 <br /> 12 <br /> Area Code Phone Number Area Code Fax Number <br /> 2"c <br /> Contact Person Business Email Address: ,,j7 3 ` y Preferred Primary Communication: Mail Email <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner):f . <br /> Name <br /> Owner Address: ? <br /> Street City State DO <br /> Owner Phone Number: ( ) Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: — _ _ _ (4-Digit Number) (See instructions.) <br /> 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be, true, accurate and compI t „. <br /> SIGNATURE. w <br /> �=- DATE <br /> PHONE D' f7- 7 <br /> NAME( int) TITLE <br /> t � ' <br /> DTSC Form 1358(6/08) <br />