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FrSubparts, C,gen la-CaliforniaWla Environmental Psn Agency Dcent of ox c Substances Control -HMP P.u, Box 806,Sacramento,CA 95812-08W PERMANENT STATE ID NUMBER APPLICATIONPlease type or neatly print in ink. Please review the line-by-line instructions carefullyTo check on the status of our r uest, o to www, wts.dtsaca. ov and click on Rc ns. UMBERREQUESTS Check all that apply. (See instructions.I am applying for a now permanent California ID number as a hazardous waste: QGenerator C]Transporter Reason for new number. A. E] Neverhadanumber B. ❑ Businessmoved C. 9 Legal ownerof business changed our business generates greater than 10 RA hazardous waste other then those hazardous waste listed in 40 CFR 261.5 (c)and(d).per month, complete Form 8700-12 for an EPA (federal)ID number, CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE 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. 8. Sim/Facility/Business Name(Include DBA): Plaza Liquor#1 (See instructions.) 7. Site Location: 800 S. Cherokee Ln. Street Lodi CA 95240 San Joa uin city State Zip County 8. (a)Federal Employer ID Number 102819371 (b)Board of Equalization Fee Account Number b is only required from generators of greater than 5 tons per calendar ear. s. Mailing address: 800 S. Cherokee Ln. (See instructions.) Street Lodi CA 95240 City State Zip 10. Site contact Person: Govinder Sin h Atwal (See instructions.) First Name Last Name Contact Person Address: 800 S. Cherokee Ln. Street Lodi CA 95240 City State Zip Contact Person Phone Number: (20e) 5344840 Fax Number. ( ) Area Code Phone Number Area Code Fax Number Contact Penson Business Email Address: serviallll uor ahoo.com Preferred Primary Communication: W Mail ❑ Email 11. Legal Business Owner(not property owner): GOVlndef Sin h Atwal (See instructions.) First Name Last Name Owner Address: 800 S. Cherokee Ln. Street Lodi CA 95240 City State Zip Owner Phone Number: (zos)534-1840 Fax Number: ( ) Area Code Phone Number Area Code Fax Number (See instructions.) - 12. Standard Industrial Classification(SIC)Code for the Site: 5 5 4 1 (4-Digit Number) (See instructions.) 13. Certification: 1 certif4under enalty of law that the info ation on ths document was prepared to the best of my knowledge andbelief to be,tme, ocd com late. SIGNATURE DATE4-15-16 NAME(print) mal Singh Atwal TITLE Manager PHONE (209) 534-1840 DTSC 1358(5179/15) y_- ..:�