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Stale of California-Ca"nla Enwrorer"Mat Protection Agency Deparanent of Toxic Substances Coiu(ol-GISS <br /> z..,. P.O.Box 808,SacmnenMe,CA 95812.0806 <br /> CAUFORNIA HAZARDOUS WASTE PERMANENT 10 NUMBER APPLICATION <br /> I to or amith dart in rn. Pwam amaw ter.&*-t>y4m ankuctlo a ca+ek*v- <br /> To check on dre statue of yow reqwsL go ro NO dirk m Repmu <br /> NEW NUMBER REQUESTS cer car.am lest appry. (See w►structions-) <br /> 1. 1 am acolying for a now permanent California ID numrber as a hazardous waste: ® Genorator OTransporWr <br /> Reason for now number. A. [] Never had a number B. [] Business moved C_ a Legal owner of business changed <br /> irymr bvsmes`e *s greater tlian 900 kg of RCRA hazardous waste per monM.contact US EPA for a federal ID number. M� <br /> CHANQU TO§TALUS OR WORMATION FOR AN EXISTWO D NUMBER (See instructions.) <br /> For existing ID number. C A — <br /> ❑ 2. 1 am updating to.." address andkr conlaot vtfo nQbw only. <br /> r-1 3. I am inacOvating this ID Number. <br /> D 4. 1 am reaciivabrry V*s 10 Number. <br /> 5. 1 am changing the bus nese name only,no owonrahq charge. <br /> �...._ {See e►es�clrorlsJ <br /> 6. Site/FaaTfyf&rsinesa Name(trtcyae DILA): Food I11 a( T tya,To/t n <br /> 7. Site Location: <br /> ?TV <br /> ��eta s E. �f G,•'a r+T S?` - <br /> STVCjK701-, C/4 �S�oL S�►'i V Ovy��,,, i <br /> 8-(a)Federal Ermplo w 10 Nwmber �`1� 9`f�y Board of�,ee Acc int Nwe_ ,4 <br /> ((bj t>Q arty regr�►ed tion�e/>8r8�00►5 d glT•at�(heu�5 o�ru acs+ .�....rtdar year.) <br /> s. (Mailing Address: , Lei r►n t'm occQ 121W4 <br /> , (See irtshx: ons.) <br /> swam <br /> W)h n Gtm vC'44 �y f!2 YYS <br /> cxr state Zip <br /> 10. site Cantad Person: - S(/►1 �/ �. R u ryl (sea ir�rt.�vau.) - <br /> F"Nate Lsst Name <br /> Contact Person Address: --- LB.S �`. l�y.+►o y S7 <br /> y surae ata <br /> Contact Person Ptrone Number- (��71 -S"40'i / O Fax Nur V r � Jay 0 V� <br /> Arae Cafe t""Number Ama Cade Fax"Umber <br /> Contacx Person Business Email Adldress: Preaerrea Y Commw„catra,: a ❑Emaa <br /> -� / (See italnrrxions.) <br /> 11. Legal Business Own Legal (trot PmP�y �):_j O 4 In ylG ti G A <br /> C.... (e1n C,1,vCca 1711,.,' v/An.CMVccs �?�/ 9169Sryr <br /> staAe Zia <br /> Owner Phom Nurrher. /!-)de Phan&Axl&` Fax NwdmrArea Code Fax M <br /> UMW <br /> 12. S'tsndard Industrial Gla sircamion(SIC)Code br nue Ste- _ (•-aga Number) (See vak000ns.) <br /> 13. Gmbfk*jon: r certify under pena4y of taw that Ute i►dior""bon an fees document ma s prepared a"beef of my knorde4ga and <br /> beA d fo be.km.mudala and oort>s ile. <br /> SIGNATURE _ dtc1 _ DATE <br /> NAME(print) GQ TITLE_,--- PHONE '7-'9' <br /> LJ <br /> DTSC Fant 1356(8006) <br /> VO 39Vd 3m3s llvl noon 3NtJTri z5zvCz9SZL EO :OT eeez,9zise <br />