Laserfiche WebLink
• s <br /> Transmission <br /> LS9 Monday , 2019 - 05 - 20 14 : 21 2097156630 <br /> Date Time Type Job # Length Speed Fax Name / Number Pigs Status <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 2019 - 05 - 20 14 : 20 SCAN 07528 0 : 11 28800 9163233500 1 OK - - V . 34 AB31 <br /> Slate of California – California Environmental Protection Aqency Department of Toxin Substances Control <br /> Office of Environmental Information Management <br /> PERMANENT STATE ID NUMBER APPLICATION <br /> N%ase type orrinp I legibly in ink. - <br /> NEW NUMBER REQUESTS Check all that apply. <br /> ❑ 1 . 1 am applying for a new permanent California ID number as a hazardous waS�e: ❑ Generator 0 Transporter' <br /> Reason for a new number- A. ❑ Never had a number B . n Business moved Co. ❑ Legal owner of business clanged <br /> If your business genorates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 281. 5 <br /> subparts (c) and (d) per month, please complete Form 8700-12 for a federal EPA ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number: C AL12, Q O Q `� <br /> ❑ 2. I am updating the mailing address andfor contact information only. <br /> ❑ 3 . I am inactivating this ID number. <br /> 1<4. I am reactivating this ID number. Reason (please select one <br /> A. �q Verification Questionnaire 8, Cl Other <br /> ❑ 5, 1 am changing the business name only, no ownership change , { �. <br /> B. Site/Facilityt8usiness Name (Include PEA i <br /> t1 !� <br /> 7. Site Location : 1 t5 7 < _�!' � � S t •- r� 1 / nn,.� ^ — - - <br /> State 1 Zip Code County <br /> City q7/ _ C�J . [l57 (b) Board of Equalization Fee Account Number,. <br /> 8. (a) FedeYel Employer ID Number i r- <br /> ((h) is only required from generators of granter Than 5 tons per cafcndarye ar'.) <br /> 9. Mailing Address : l _ — <br /> Stre YiJ • 1 Qri /' � qs L 05 — <br /> Cif �. Sttolia— ., _ Zip Code <br /> 10. Site Contact Person : 0,._ Q5 <br /> FirstName <br /> �v7 Last Name <br /> Contact Person Address: _ tNv e2 ,J g4..�tLJ — • <br /> t ee[ 5 05 <br /> CityState Zip Code <br /> Contact Person Phone Number: ( � ) ,�W. `O � ! Fax Number. �•_) _Area Code Phone Number Arca Code Fax Number <br /> Contact Person Business Email Address: <br /> 11 . Legal Business Owner (not property owner) : _ _ •- - <br /> Name. <br /> Owner Address: ._ City Slate Zip Code <br /> Street <br /> owner Phone Number: C _ Fax Number: L — <br /> Area Code Phone Numher Area Code Fax Number . <br /> L. Standard Industrial Classification (SIC) Code for the Site: 7 e3 (4 -Digit Number) <br /> 13. Certification: I certify under penalty of I w I at the into alien on t document was prepared to the best of my knowledge and <br /> belief to be true, accurate and <br /> ` <br /> SDate(handwritten �� o <br /> f Title l7i.t/_ �_ . PhanaCgoq) • 7I L G �?`Y_� <br /> Name (print. . <br /> a� <br /> DTSC Farm 1358 (1719118) , <br />