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d ti State of California - California Environmen otecdon Agency ')epartment of Toxic Substances Control - GISS F .'.O. Box 806, Sacramento, CA 95812-0806 wow o Print CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line -by-line instructions carefully. (r�[ 10 check on the status of your request, go to www.hwts,dtsc_ca _-qov and dick on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) 1. 1 am applying for a new permanent California ID number as a hazardous waste: Nf Generator []Transporter Reason for new number. A. ❑ Never had a number B. ❑ Business moved C. Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste per month, con c US EPA for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER For existing ID number. C A L- d O d 0 -_L 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 changing the business name only, no ownership change. 01 p 6. Site/Facility/Business Name (Include DBA):� 7. Site Location: instructions.) J`,ji� a 4 2011 RM(T/ VIC SLS - _ --1 (See instructions.) s"t;t I�� ml ' C � ' �l5"2 I � 5� �at� v i en City 8. (a) Federal Employer ID 9. Mailing Address: ii Zip County of Equalization Fee Account Number ((b) is only required from generators of greater than 5 tons State ger calendar year.) (See instructions.) L- (See instructions.) 10. Site Contact Person: t-.-V't C- ( dJe First Name Last Name Contact Person Address: - i 4155- Street,D.U q V `7 City M( '"� ate Zip_�y Contact Person Phone Number: ) 9 (1'g6-r2L j Fax Number. (( 07) 177- 1 ( 5`85— Area Cglde Phone Number} Area Code Fax Number 1�1i �(.y.-- 1��5 kgltGil^j1�d�,v yQi��Civ� Lv��✓i Contact Person Business Email Address: I Preferred Primary Communication: Mail 09 Email 11. Legal Business Owner (not property owner): Owner Address: �ucc� Owner Phone Number. fie E!"/1Z<ttlA t/' MW CAY� SL' Fax Number. (� _ Area Code (See instructions.) 12. Standard Industrial Classification (SIC) Code for the Site: 3 ! -3 � (4 -Digit Number) (See instructions.) , 13. Certification: 1,gertify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, t accurate and complete. SIGNATURE' DATE NAME (print) _. � , Ci&.t,-5l-�5 TITLE T[ZkV- A�&5 ��f— PHONE q77 J 2 I DTSC Form 1358 (6108)