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CAD ^-m s;33 <br />EPA ID NUMBER Page,2 of L. <br />HAILING ADDRESS, IF DIFFERENT: <br />COMPANY NAME (DBA) <br />STREET <br />CITY <br />COUNTRY <br />CONTACT PERSON <br />(only complete if nm USA) <br />(first Name) <br />STATE ZIP <br />(List Name) <br />PHONE NUMBER( <br />III. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE: <br />Use either one or two SIC codes (a four digit number) that best describe your company's products, services, or industrial activity. <br />Example: 7384 Photoflnishine lab 3672 Printed circuit boards <br />First: 3211 flat glass Second: 3231 glass products <br />IV. PRIOR PERMIT STATUS: Check yes or no to each question: <br />YES NO <br />El El <br />11 El <br />❑ ❑ <br />❑ ❑ <br />1. Did you file a PBR Notice of Intent to Operate (DTSC Form 8462) in 1992 for this location? <br />2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim <br />status for any of these treatment units? <br />3. Do you now have or have you ever held a state or federal full permit or interim status for any other <br />hazardous waste activities at this location? <br />4. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br />are now notifying for at this location? <br />5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator? <br />V. PRIOR ENFORCEMENT HISTORY: Not required from generators only notifying as conditionally arenpr. <br />YES NO <br />❑ ❑ Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or final <br />orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health <br />enforcement agency? <br />(For the purposes of this form, a notice of violation does not constitute an order and need not be [sported unless <br />it was not corrected and became a final order.) <br />❑ If you answered Yes, check this box and attach a listing of convictions, judgments, settlements, or orders and a copy <br />of the cover sheet from each document. (See the Instructions for more information) <br />DTSC 1772 (1193) Page 2 <br />