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T CAL )RN1A DEPARTMENT OF HEALTH S. _VICES Re-n �obbinS <br /> Hazardous Waste Management Branch 5,10 — a v4 3 <br /> APPLICATION FOR <br /> CALIFORNIA EXTREMELY HAZARI,� a fi16 TSPOSAL PERMIT* <br /> a��w* S8P <br /> WASTE PRODUCER: PLEASE CHECK APPLICABLE PERMIT REQUEST a~ �1� For Office Use Only: <br /> l New Permit t' Permit No. �Q <br /> ❑ Renewal Permit (Previous Permit No. Date ;) `V �Q Date Handled <br /> I!! <br /> ❑ Amendment (Current Permit No. Date <br /> ❑ Verbal Permit (No. Date )`' <br /> (lfgiven verbal emer ency permit by telephone) :y <br /> stL1�Y <br /> t'wase type or print clearly. Proride all information requested,since ornission will result in delay or denial of perrnit. Allow 15 days process time from <br /> dayofpermit recc)ipt• <br /> WASTE PRODUCER: Name of Firm Telephone No.(Include Area Code'. <br /> Street and No. (or P.O. Box) e-10 N.S E J��NNT County <br /> Z'7 4 0 Z S.nrl,Rc P_ S FF ry TD A, (N <br /> City ^T- t\L� State l /� Zip Code C S 3 7 C <br /> Pick-up A1d_dress(If different than above) 1 <br /> TRN C`r, CA <br /> Applicant (T' <br /> ped) Title <br /> Signature f Appl' t Date <br /> Mt 0G/06 /gG <br /> knl/ �41,gl <br /> PROPOSED HAULER:Name of Firm <br /> ZERO WASTE .sYSTFM(, 1NC <br /> Strut and No. !or P.O. Box) <br /> City State Zip Code <br /> LI OSS <br /> Hauler No. �I Q <br /> EPA ID NUMBER <br /> CA 0 0 -7 16 'l ?-'o <br /> PROPOSED DISPOSALNamc of Firm <br /> (OR OTHER) C-AsMK L,IESOvAIQCES <br /> FACILITY: .rrect a„o No. (or P.U. Aux;; <br /> o_ <br /> City State Zip Code <br /> Sc nTCA, C <br /> �p "LI ! eYrYrsse. / <br /> HAZARDOUS MATERIALS MANAGEMENT SECTION OFFICES: <br /> 714/744 P Street 2151 Berkeley Way, Rm. 119 55.35 Last Shields Ave. 107 South Broadwat <br /> Sacramento, CA 95814 Berkeley,CA 94704 Fresno, CA 93727 Rm. 7012 <br /> (916) 322-2337 (415) 540-2043 (209) 291 6676 Los Angeles. CA 90012 <br /> (213)620-2380 <br /> 'Required for handling or disposal of extremely hazardo.is wastes. (Section 66570, Title 22,CAC). <br /> 8015.0(1 <br />