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State 4 California-Cabfomia Environmental Protection Agency Department of Toxic Substances Control-GISS <br /> P.O.Box 806,Sacramento,CA 95812-0906 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly pant in ink. Please review the tine-by-line Instructions carefully. <br /> To check an the status of your request,go to .h ov and click on Reports. <br /> NU UE Check all that apply. (See Instructions.) <br /> 1. I am applying for a w permanent California 10 number as a hazardous waste: [] Generator Transporter <br /> Reason Ifornew,numbe. A C1 Never had a number B. ❑ Business moved C_ C]Legal owner of business changed <br /> If your busingenerates ater then 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br /> AN TATOS Q$INFORMaTION FOR AN QMD&gJLWMSEg (See instructions.) <br /> For existing ID number, QA -0- cj -C- Z— 71 L-- L ` <br /> [] 2. 1 am updating the ma ling address and/or contact information only. <br /> 3. 1 am inactivating this D Number, <br /> j(4. 1 am reactivating this D Number. <br /> 5. I am changing the bu Mness name only, no ownership change- <br /> 6- SitelFacli /business Nare(Include DBA): <br /> , /► (See instructions.) <br /> 7, <br /> Site Location: ��� S �� oll��f es- <br /> Street <br /> s- <br /> stree e� -k4-o 11 C4114 -- <br /> S'lo 5A^1 <br /> City state Zip County <br /> 8.(a)Federal Employer ID Numb er 01 g Z (b)Board of Equalization Fee Account Number <br /> ((b)is on! required from generators of realer than 5 tons per calender ar.) <br /> 9. Mailing Address: 1 2 O r-Z o (See Instructions.) <br /> stree <br /> city State 71. <br /> -- <br /> 10. Site Contact Person: ply q lz-� (See insfructonsj <br /> First Name Last Name I <br /> Contact Person Address: /27S vJ Jit <br /> Street — 514-1-11,C- <br /> city <br /> A •Lcity State zip <br /> Contact Person Phone Number: t •-�) 6 Z y�7`6 7 Fax Number. <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business ail Address: Preferred Primary Communication-, Mail Email <br /> 11. Legal BusinesOwner(not roparty owner; " 0 i M 4-► i4 t-�. (See insuctions.) <br /> Omer Address: 17e I ovi <br /> wnis S +.,c k uvt C Cd o <br /> street City State z10 <br /> Owner Phone Numbef Fax Number (�) <br /> AM Code Phone Number Area Code Fax Number <br /> L12- Standard Industrial Classifi�tlon(SIC)Code for the Site: _ (4-Digit Number) (See instructlons.) <br /> 13. Certification: l certify under penalty of law that the information on this document was prepared to the bast of my knowledge and <br /> belief to be, true,accur ate_ <br /> SIGNATU �d' DATE t' V J Z D1 0 <br /> NAME(print) DI^141�� F'IJ TITLE YV--L PHONE SS) L— <br /> orsc Form�358(aros> <br /> 6>!>•i 39t�d Sd0HaVH N173-13 ZZ9989b60Z ZZ :ZT 0T0Z/L0/S@ <br />