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State of California-California Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> —» -� P.O.Box 806,Sacramento,CA 95812-0806 <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.disc.ca.aov_and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator E]Transporter <br /> Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br /> !f your business generates greater than 100 kg•of RCRA_hazardous waste per rnonfh, contact US EPA for a federal 1D number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number. C A L Q 0 _ -L (0 <br /> [] 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 /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> <br /> me(include DBA): MQ(fIS W,0S (1 C3f Coy Cly LctllC. dL^cr NIGiY1 QC <br /> 7. Site Location: J-51 lav vSiPt+n <br /> Street m arN(A (Au n <br /> CityState Zip County <br /> 8. (a)Federal Employer ID Numbercl�'�+�_t!7_�ogv ._, Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> (See instructions.) <br /> 9. Mailing Address: t Street '7 <br /> City State Zip <br /> 10. Site Contact Person: WUYC� �oY1.11 (See instructions.) <br /> First Name ti Last Name J <br /> Contact Person Address: <br /> Street mans-an A 9 ) W <br /> City State Zip <br /> Contact Person Phone Number: Fax Number: (AL)d* " <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: Preferred Primary Communication:F-1 Mail ❑Email <br /> A (See instructions.) <br /> "off <br /> 11. Legal Business Owner(not property owner): 1" of f ti <br /> .11 1,� r '614-0 <br /> Owner Address: cT �t(ame c�r�QY�1 <br /> Street T City State Zip <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: 1 certify andpenalty of law tha the information on this document was prepared to the best of my knowledge and <br /> belief to be,Ir e, accurate•n rr 1 te. <br /> r <br /> SIGNATURE DATE <br /> f� <br /> NAME(print) 66V\j(v6 �(I) -nw o ITT LE�.!1()C fUO-ffr` PHONE IC�Gy.{}:7A'�1' <br /> DTSC Form 1358(6/08) <br /> coo[A NI121111IIIg VDH,LNVN LT9E6VZ60Z XVJ LO:ZT OTOZ/9T/60 <br />