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EPA ID NUMBER CAD041840002 Page 2 of 6 <br /> MAILING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME (DBA) <br /> STREET SAME AS OTHER SIDE <br /> CITY STATE ZIP <br /> COUNTRY <br /> (ody complete if not USA) <br /> CONTACT PERSON PHONE NUMBER( <br /> (First Name) (1Jst Name) <br /> III. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE: <br /> Use either one or two SIC codes (a jour digit number) that best describe your company's products, services, or industrial activity. <br /> Example.- 7384 Phorofinishine lab 3672 Printed circuit boards <br /> First: un('9 GEN MEDICAL HOSPTIAL Second: <br /> IV, PRIOR PERMIT STATUS: Check yes or no to each question: <br /> YES NO <br /> ❑ © 1. Did you file a PBR Notice of Intent to f <br /> y Operate (DTSC Form 8462) in 1992 for this location? <br /> ❑ ® 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim <br /> f--t status for any of these treatment units? <br /> El El 3. Do you now have or have you ever held a state or federal full permit or interim status for any other <br /> hazardous waste activities at this location? <br /> ❑ El 4. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br /> F1are now notifying for at this location? <br /> l 1 �q tq 5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator? <br /> V. PRIOR ENFORCEAfENT HISTORY: Not required from generators only nothing as conditionally exempt. <br /> YES NO <br /> ❑ 0 Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or fatal <br /> orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health <br /> enforcement agency? <br /> (For the purposes of this form, a notice of violation does not constitute an order and need not be reported unless <br /> it was not corrected and became a final order.) <br /> ❑ If you answered Yes,check this box and attach a listing of convictions,judgments, settlements, or orders and a cop <br /> of the cover sheet from each document. (See the Instructions for more information) <br /> DTSC 1772 (1193) Page 2 <br />