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RECEIVED State of California - California Environmental Protection Agency Department of Toxic Substances Control - HWMP A U U 2 2 M18 P.O. Box 806, Sacramento, CA 95812-0806 PERMANENT STATE ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line -by-line instructions carefully. EN HEAL v!riUN1VICIV 1HL To check on the status of your request go to ntta:/lwww.nwts.gtsc.ca.poy an, cltcK on eeeports. (f EWNU IFi$RREQUESTS Check all that apply. (See instructions.) ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ 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 other than those hazardous waste listed in 40 CFR 261.5 subparts (c) and (d), per month, complete Form 8700-12 for an EPA (federal) ID number. (see instructions.) For existing ID number: C A -L A -0- A f?_ _fp_ Z_ -5 4 ❑ 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. Reason (please select one): A. ❑ Verification Questionnaire B. NE Other ❑ 5. 1 am changing the business name only, no ownershia channe. 6. Site/Facility/Business Namd (Include DBA): 7. Site Location: 8. (a)• Federal Employer ID Number County (b) Board of Equalization Fee Account Number_ I is only required from generators of greater than 5 (See instructions.) tons per calendar �r e�� l4 _ A I (See instructions.) C 9. Mailing Address: J /+ •�/ /� Stre t - ---- - � 15 C State -zip (See instructions.) 10. Site Contact Person: T First Name Last Name D w' Contact Person Address: f � G��Ile Stir et -- - �Al CiTI _ State Zip 4 Contact Person Phone Number: 2 Fax Number: Area Code``..)) hone Num e�r,( /� A.rei Cnde �fFFaax Number Cnntact Person Business Email Address: vv ©��` �J �3 /V 60ifkm`O5ffirfiunication: ❑_Mail &Emai 11. Legal Business Owner (not property owner): /V040 �� O- (See instructions.) dd /� � Name .l / !.- �, Owner Address: l -! l3 __A1 __-AM " " � ��` I (/ Stree City tate /' Zi Owner Phone Number:'��JJ ___ Fax Number. (_ 1Z��dbc Area Code Phone Num er Area Code Fax Number 12. Standard Industrial Classification (SIC) Code for the Site: e instructions.) j 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and ! belief to be, true. ccurate and complete. / I SIGNATURE __ DATE NAME (print} TITLE G�%�/L PHONE DTSC Fonn 1354 (01117)