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State of California—California Environmental Agency Department of Toxics Substances Control <br /> Linda S.Adams <br /> Secretary for Certified Appliance Recycler Application <br /> Environmental Protection <br /> Please submit to: <br /> Department of Toxic Substances Control <br /> Attn:Consumer Products Section-CAR application <br /> 1001 "1"Street, 11th Floor <br /> P.O, Box 806 <br /> Sacramento, Califomia 95812-0806 <br /> Or <br /> CAR@dtsc.ca.gov <br /> Before you may remove"materials that require special handling"(MRSH)from a major appliance,you must be <br /> approved as a Certified Appliance Recycler, pursuant to Health and Safety Code Section 25211 et seq (AB 1447, <br /> 2007).You must also provide evidence of your CAR status to scrap metal facility. <br /> Once a certificate is issued, DTSC will notify the certified uniform program agency(CUPA)in your jurisdiction <br /> responsible for inspecting the certified appliance recycling facility. <br /> Certificates issued will be valid for three years. Once your certification has expired,you are no longer a Certified <br /> Appliance Recycler.In order to continue operating as a CAR, you must renew your certification before the expiration <br /> date. <br /> Please note:Any changes to the information provided on the Certified Appliance Recycler Application must be <br /> submitted to DTSC in order for the certification to be valid. <br /> ® Renewal for CAR Number: 0 S94 Please note: Entire application must be completed. <br /> 1. Business Information <br /> Business name under which the applicant operates: sl ln5 YYl PeG:.Q. lYIQ/lQ�>�J4Lt�Jt <br /> Physical Address: 1 QQQ SI�tJTw\ GUCOuR Skfe,6t - � oc k , CSI ngs2-ab <br /> Mailing Address: 1000 SoCi"� tP V f o r A �ke2T- �T `- CA 93 2 0 E <br /> Business Phone Number: ( 2-M) 9y - 1/000 Business Owner Name: CSI M4 M e-&a ►�u�� <br /> Owner Address: (Do SQ1r(`-�- y`ft cS+Aa .t 7C!r CA <br /> Owner Phone Number: (510 ) q 1-02-5$00 Email Address(if available): Maff•7-,Mer 0,5 1 rr><s hl 100M <br /> 2.)Hazardous Waste generator identification number: CA 00 29 L1'3,5-c>-7 14 <br /> 3.)Is your organization required to obtain a storm water permit? ® Yes ❑ No <br /> 4.) Is your organization required to file a hazardous materials business plan? 15c1 Yes ❑ No <br /> 5.)Tax identification number,assigned by the Franchise Tax Board: 1 , _1 8 23 <br /> 6.)Attach a copy of a business license to this application. <br /> 7.) If applicable,attach a copy of conditional use permits issued by the appropriate city or county to this application. <br /> DTSC 1428(11(04/2010) page 1 oft <br />