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ern IU NUMBER CAL t1UU(14JU/8 Page 2 of <br /> 2.1 <br /> MAELING ADDRESS, IF DIFFERENT: <br /> COMPANY NAME (DBA) ' <br /> STREET <br /> A <br /> CITY STATE ZIP <br /> COUNTRY <br /> (only complete if not USA) <br /> CONTACT PERSON PHONE NUMBER(_) <br /> (First Name) (Lan Neme) <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 activirv. <br /> Erarnple: 7384 Photofinishing lab 3672 Printed circuit boards <br /> First: 8062 MED/SURG. HOSPITAL Second: <br /> IV. PRIOR PERMIT STATUS: Check ves or no to each question: <br /> YES NO <br /> ❑ 0 �. <br /> 1. Did you file a PBR Notice of Intent to Operate (DTSC Form W2) 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 /> status for any of these treatment units? <br /> ❑ © 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 /> ❑ ® 4. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br /> arc now notifying for at this location? <br /> ❑ ® 5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator? <br /> V. PRIOR ENFORCEMENT HISTORY: Not required from generators only notifying at conditionally eumm. <br /> YES NO N/A <br /> ❑ ❑ Within the last three years, has this facility been the subject of any convictions, judgments, settlements, or foul <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 A <br /> of the cover sheet from each document. (See the Instructions for more information) <br /> DTSC 1772 (1/93) Page 2 <br />