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State cf California—Californiavironmental Protection Agency Department of Toxic Substances Control-GISS Print <br /> Reset Form P.O.Box 806,Sacramento,CA 95812-0806 <br /> CALIFOR;check <br /> IA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly print in ink. Please review the line-by-line instructions carefully. <br /> on the status of your request,go to www.hwts.dtsc.ca. ov and click on Reports. <br /> NEW NUMBER RE UEST Check all that apply. (See instructions.) <br /> 1. I am applying for a n permanent California ID number as a hazardous waste:}Generator ❑Transporter <br /> Reason for new number A. ❑ Never had a number B. ❑ Business moved C. Legal owner of business changed <br /> If your business generates g eater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br /> CHANGES TO STATUS ORI INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number: A <br /> ❑ 2. 1 am updating the mai ing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this I Number. <br /> ❑ 4. 1 am reactivating this I Number. <br /> ❑ 5. 1 am changing the bu iness name only, no ownership change. <br /> �� (See instructions.) <br /> 6. Site/Facility/Business Na a(Include DBA): <br /> 7. Site Location: <br /> Stre t <br /> L <br /> ity State Zip County <br /> 8. (a)Federal Employer IDNumber 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: C - W. <br /> Street <br /> o de-To <br /> City State Zip <br /> I A (See instructions.) <br /> 10. Site Contact Person: mom'�Il VJ <br /> First Name <br /> aName Las Name <br /> Contact Person Address: Ll - 991` <br /> Strdet <br /> M:iC '� <br /> i State Zip <br /> Contact Person Phone Nt mber:.(1 71`, �� W Fax Number: (_) <br /> Area ode Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: e( Xo COtteferred Primary Communication: Mail ❑Email <br /> (See instructions.) <br /> 11. Legal Business Owner(n)t property owner): 114 U haw-VI r-1G'cL� �1 Z ��'���`� <br /> � q T E Name- T��� C <br /> Owner Address: /�L .6-C S <br /> Stre tCity State Zip <br /> Owner Phone Number: _c -21• a 7?3 Fax Number: (_) <br /> rea Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Clas fication(SIC)Code for the Site: (4-Digit Number) (See instructions.) <br /> 13. Certification: I certify unc er penalty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be, true,accurat and complete. <br /> SIGNATURE <br /> DATE <br /> NAME(print) 1 1�� �V�^ ITLE /'79/6 1 i PHONE �.! '• �f [�S o l�� <br /> DTSC Form 1358(6/08) <br />