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_i® TR. ,MISSION VERIFICATION REPORT <br /> TIME 04/23/2018 09:17 <br /> NAME THE UPS STORE 4829 <br /> FAX 2098304362 <br /> TEL : 2098301526 <br /> SER.0 BROG6V617663 <br /> DATE,TIME 04/23 09:16 <br /> FAX NO./NAME 19163233500 <br /> DURATION 00:00:26 <br /> PAGE(S) 01 <br /> RESULT OK <br /> MODE STANDARD <br /> ECM <br /> State of California—California Environmental Protection Agency <br /> DapartmeM of Toxic Substances Control •FtWM1AP <br /> P.0 BOX 806. <br /> PERMANENT STATE ID NUMBER APPLICATION Sac emento,CA 95812-0806 <br /> please type or neatly print In ink. Please review the Ilne-0y-line instructions aarefuny, <br /> NEW NUTo ehaok on the status of our r uost, o to htt tlrwww.hwtsoteaca. or and C ICk on Re orts. <br /> MBER REQUESTS Check all that apply- <br /> 1. I (Seo instructions.) <br /> am applying for anew <br /> Permanent California ID number as a hazardous waste:y�(�Generator ❑Transporter <br /> Reason for new number: A. ❑ Never had a number B, ❑ Business moved C, ❑ Legal owner of business changed <br /> 11 by its(c) ss generates greater than 100 k9 of RCRA hazardous waste other than those hazardous waste fisted in 40 CFR 261.5 <br /> subparts(c)==ono",'permonth,complete Farm 8700-12 for an EPA(federal)(D number. <br /> =MnVmber � <br /> TO STA US R INFORM TION FOR ANE (STING STATE ID UMBER <br /> ID number, C A _ (See instrVcbpns.) <br /> pdating the mailing address and/or contact information only, <br /> nactivating this ID Number.activating this ID Number. Reason(please select ane): A. O Venieation Questionnaire B ❑ Other <br /> changing the business name only, no ownership change. <br /> 6. SitefFadlity/Business Name(Induce DBA): _ [AY,/.5 YYLtf W1 0<{ Q• C (See instructions.) <br /> J � �( ) an e a Yv�or.� <br /> 7. Site Location: ( to ' <br /> 5 t G• <br /> P IL <br /> s39K S�io, <br /> 8.(a)Federal Employer l0 Number S 9 State zip County <br /> (b)Board Of Equalization Fee Account Number <br /> r' ' ((b)is only required tram generator at greater than 5 tons per Calendar year.) <br /> 9. Malting Address: 6 15 t 1�P 4 ra vt <br /> t <br /> Sveet I Ih r' W".4.L (See instructions,) <br /> city tat ' 9 r3°Y <br /> Zip <br /> to. Site Contact Person: Ih/ <br /> (See 1nslntCffonsj <br /> First1 sore last Nam <br /> Contact Person Address: _ oil�y / <br /> Street L1 <br /> State <br /> Contact Person Phone Number. u 33 /_�3q <br /> FaX Number t t <br /> Scanned with CamScanner <br />