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State of California — California Environmental Protection Agency Department of Toxic Substances Control - GISS <br />Reset Form I Print P.O. Box 806, Sacramento, CA 95812-0806 <br />CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br />Please type or neatly print in ink. Please review the line -by-line instructions carefully. <br />_ To check on the status of your request, qo to www.hwts.dtsc.ca.uov and dick, Reports. <br />NEW NUMBER REQUESTS Check all that apply. (See Instructions.) <br />❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator Transporter <br />Reason for new number: A_ E] Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br />If your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number. <br />CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER <br />For existing ID number. CA L 0 0 0 2 7 5 3 0 8 V fS <br />❑ 2. 1 am updating the mailing address and/or contact information only. <br />❑✓ 3. 1 am inactivating this ID Number. <br />F14. 1 am reactivating this ID Number. AUG 2i 2011 <br />❑ 5. 1 am changing the business name only, no ownership change. SAN JOAQUhd COUN <br />ENVIRONMEWAL <br />6. Site/Facility/Business Name (Include DBA): Love's Travel Stops #223 <br />7. Site Location: 1553 Colony Road <br />Street <br />Ripon CA 95366 San Joaquin <br />City <br />8. (a) Federal Employer ID Number <br />State Zip County <br />Board of Equalization Fee Account Number <br />is only required from generators of greater than 5 tons per calendar <br />9. Mailing Address: <br />PO Box 26210 (See instructions.) <br />Street <br />Oklahoma City OK 73126 <br />City State Zip <br />10. Site Contact Person: Kimberly <br />First N <br />Contact Person Address: PO Box 26210 <br />Street <br />Oklahoma City <br />Contact Person Phone Number:( 05 ) 687-1060 <br />Area Code Phone Number <br />Mills <br />Last Name <br />(See instructions.) <br />OK 73126 <br />State Zip <br />Fax Number:4( 05) 463-3689 <br />Area Code Fax Number <br />Contact Person Business Email Address: kimbedy.mills@loves.com Preferred Primary Communication: F-1 Mail [DEmail <br />11. Legal Business Owner (not property owner): Loves Country Stores of California (See instructions.) <br />Name <br />owner Address: PO Box 26210 Oklahoma Citv OK 73126 <br />Street City State Zip <br />Owner Phone Number:4( 05 ) 302-6640 Fax Number:4( 05 ) 463-3640 <br />Area Code Phone Number Area Code Fax Number <br />12. Standard Industrial Classification (SIC) Code for the Site: 5 5 4 1 (4 -Digit Number) (See instructions.) <br />13. Certification: I certify under penalty of taw that the information on this document was prepared to the hest of my knowledge and <br />belief to be, true, accurate and complete. �q <br />SIGNATURE �? �.� V A \/L `:� DATE <br />V W. Lo0.Si � t <br />NAML (print) Y ' tv\ _ TITLE . PHONF 16h (0`00 <br />LJ I JV ru1111 IJJo to/uo) <br />