Application - Toxic Substances Control Department�� Costa Mesa Sanita -qa���r -,� District
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... an Inbepenbent Special District
Board of Directors
Robert Ooten
James Ferryman
Mike Scheafer
James Fitzpatrick
Arthur Perry
Staff
Scott C. Carroll
General Manager
September 6, 2012
Department of Toxic Substances Control
GISS
PO Box 806
Sacramento, CA
95812 -0806
RE: Costa Mesa Sanitary District California Hazardous Waste Permanent
ID Number Application
Joan Revak
Sincerely,
Office Manager
Dear DTSC:
Clerk of the District
Attached is the Costa Mesa Sanitary District application for a California
Robin B. Hamers
Hazardous Waste Permanent ID Number. This application is for a CAH
District Engineer
designated number since it will be used for participation in the Door -to -Door
(949) 631 -1731
household hazardous waste collection program operated by CR &R, Inc.
Alan R. Burns Please contact me if you have any questions.
Legal Counsel
Address
628 W. 19th Street
Costa Mesa, CA
92627 -2716
4
164tPrinted on
Recycled Paper Protecting our community bealth anb tlje environment by providing solib waste anb sewer collection services.
www.crosbca.gov
Sincerely,
Marcus D. Davis
Treasurer
Scott Carroll
Phone
General Manager
(949) 645 -8400
Fax
(949) 650 -2253
Attachment
Address
628 W. 19th Street
Costa Mesa, CA
92627 -2716
4
164tPrinted on
Recycled Paper Protecting our community bealth anb tlje environment by providing solib waste anb sewer collection services.
www.crosbca.gov
State of California — California Environmental Protection Agency Department of Toxic Substances Control - GISS
P.O. Box 806, Sacramento, CA 95812 -0806
FgriM. - ^ P,,rilnt
CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION
Please type or neatly print in ink. Please review the line -by -line instructions carefully.
To check on the status of your request, qo to www.hwts.dtsc.ca.gov and click on Reports
NEW NUMBER REQUESTS Check all that apply. (See instructions.)
1. 1 am applying for a new permanent California ID number as a hazardous waste: 0 Generator ElTransporter
Reason for new number: A. ❑✓ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed
If your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number.
CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.)
For existing ID number: C A
2. 1 am updating the mailing.address and /or contact information only.
3. 1 am inactivating this ID Number.
❑ 4. 1 am reactivating this ID Number.
❑ 5. 1 am changing the business name only, no ownership change.
6. Site /Facility/Business Name (Include DBA):
7. Site Location: 7571 Lampson Avenue
Street
Garden Grove
8. (a) Federal Employer ID Number.
Costa Mesa Household Hazardous Waste Facility (See instructions.)
CA 92841 Oranqe
State Zip County
Board of Equalization Fee Account Number EXEMPT
is only required from generators of greater than 5 tons per calendar
9. Mailing Address: 628 West 19th Street (See instructions.)
Street
Costa Mesa CA 92627
City State Zip
10. Site Contact Person: Scott
Name
Contact Person Address: 628 West 19th Street
Street
Costa Mesa
City
Contact Person Phone Number: 9( 49 )
Area Cod
Contact Person Business Email
Carroll
Last Name
CA
State
645 -8400
Code Phone Number
scarroll @crosdca.gov
11. Legal Business Owner (not property owner): CR &R Incorporated
(See instructions.)
92627
Zip
Fax Number: 9( 49) 425 -3899
Area Code Fax Number
Preferred Primary Communication: [Z]Mail ❑ Email
Name
Owner Address: 11292 Western Avenue Stanton CA 90680
Street City State Zip
Owner Phone Number: 7( 14) 826 -9049 Fax Number: 7( 14) 890 -6347
Area Code Phone Number Area Code Fax Number
12. Standard Industrial Classification (SIC) Code for the Site: 9 5 1 1 (4 -Digit
(See instructions.)
13: Certification: /certify under penalty of law that the information on this document was prepared to the best of my knowledge and
belief to be, true, accurate and complete.
SIGNATURE DATE_ a?/0(O/aO/2 --
NAME (print) %TCDTT (YtV e_nI . TITLE C7ETJI- -eA1, M/Wt1Cjj 7RtIONd'792) (pq13'—a0Y10