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Stab of California—California Environmental Pn n AgencyDE lent Of TOYFC Substances Control -HWMP P.v. Box 806,Sacramento,CA 95812-0806 PERMANENT STATE ID NUMBER APPLICATION qII l� 2 j Please type or neatly print in ink. Please review the line-by-line instructions carefully. To check on the status of your request,go to vAs.dtsc.ca. ov and click on Renorto,. NEW NUMBER REQUESTS Check all that apply. 1. 1 am applying for a now permanent California ID number as a hazardous waste: ® Generator (See instructions.) ❑Tran porter Reason for new number. A. ❑ Never had a number B. ❑ Business moved C. IM Legal owner of business changed if yourbusiness generates greater than 100 kg of RCRA hazardous waste other then those hazardous waste listed in 40 CFR 261.5 subparts(c)and(d),permonth, 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 _ _ [12. 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 o hange. 6. Site/Facility/Business Name(include DBA): Plaza Liquor#1 (See instructions.) 7. Site Location: _800S. Cherokee Ln. Street Lodi CA 95240 San Joaquin 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 (See instructions.) 10, Site Contact Person: Govinder Sin h Atwal First Name Last Name Contact Person Address: 800 S. Cherokee Ln. Street Lodi CA 95240 city State Zip Contact Person Phone Number: (209) 534-1840 Fax Number. ( ) Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: Serviallll uor ahoo.com Preferred Primary Communication: ❑■ Mail ❑ Email (See instructions.) 11. Legal Business Owner(not property owner): Govinder Sint h Atwal First Name Last Name Owner Address: 800 S. Cherokee Ln. Street Lodi CA 95240 Cit' State Zip Owner Phone Number_: (los)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: I certify under penalty of law that the info ation on th's document was prepared to the best of my knowledge and belief to be,true,accur nd corn late, SIGNATURE DATE 4-15-16 NAME(print) Rajkamal Singh Atwal TITLE Manager PHONE (209) 534-1840 DTSC 1358(5129/15)