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♦ 1 a11'j Jr x,) <br /> State of California-California Enviro�-,antal Agency L-Nartment of Toxics Substances Control <br /> G APR 2 3 nia <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, California 95812-0806 <br /> Or <br /> CAR@dtsc.ca.gov <br /> If you remove"materials that require special handling" (MRSH)from a major appliance you need to provide evidence <br /> to a scrap metal facility that you are a Certified Appliance Recycler, pursuant to Health and Safety Code Section <br /> 25211 et seq (AB 1447, 2007). <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. <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 /> 1. Business Information 4c�dl' <br /> Business name under '' Cwhich the applicant operates: s vI Yl <br /> Physical Address: -32-0-C S. E' ��C�►ted C(G . >T -StOCk f o✓1 <br /> Mailing address: �C/ 1 I' n <br /> Business Phone number: �iy l �`f`I ' _! 5s <br /> Business owner name: 1 Lc Ce, mld em+- <br /> Owner Address: 32C C, S —Ft Owdo o �� StOC l� C� q,52C,6 <br /> Owner Phone number: 2-07' N`1' /_M Email address (if available): <br /> 2.) Hazardous Waste generator identification number: CL DO'S q 57-6 <br /> 3.) Is your organization required to obtain a storm water permit? M Yes ❑ No <br /> 4.) Is your organization required to file a hazardous materials business +plan? 91 Yes ❑ No <br /> 5.)Tax identification number, assigned by the Franchise Tax Board: 4 I 2-0 x.52-4 9 <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(05/01/2009) page 1 of 2 <br />