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r 409ECEIVED <br /> FEB 0 4 2013 <br /> r1vI`,1pp ff����'������e CC"11��F'',fTT.cAA,..'�#w-34 3 3 <br /> State of California California Environmental Protection Agency RAkWPe YtAtiuYa6Cta9c0A61Ml-GIS$ <br /> sReset Fort: RBGM P.oliftAd1lit�, set2oeo6 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type or neatly print in Ink. Please review the tine-by-Ilne Instructions carefully. <br /> To check on the status of ourfatlusst,00 to WWW.hurts. .ca.noy and dick on Re rte. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> © 1. 1 am applying for a new permanent Cal•Ifomia ID number as a hazardous waste; ❑ Generator Transporter <br /> Reason for new number. A, Never had a number B. ❑ Business moved C. ❑Legal owner of business changed <br /> !f your business generates greateran 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 (See instructions) <br /> For existing ID number: CA L 0 0 0 2 8 2 5 0 1 <br /> ❑ 2. lam updating the Melling address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. 7 (-r t;(rry�t+ pj6k_ <br /> 0 4. 1 am reactivating this ID Number. <br /> ❑ 5. 1 am changing the business name only,no ownership change. <br /> 8. Site/Facility/Business Name(Include DSA): <br /> West Lane Valero (See instructions.) <br /> 7. site Location: 9484 West Lane <br /> Street <br /> Stockton CA 95210 United States <br /> cityP County <br /> 8.(a)Federal Employer ID Number S�tBoard of Equalization Fee Account Number <br /> ((b)Is onlyrequired from generators o/ rester than 5 tons per Calendar year} <br /> 8. Mailing Address: <br /> 8484 West Lane (see instructions.) <br /> street <br /> Stockton CA 95210 <br /> Cay State Zip <br /> 10. Site Contact Person: <br /> Diana Phan (See instructions.) <br /> First Name Lest Name <br /> Contact Person Address; 9484 West Lane <br /> Street <br /> Stockton CA 95210 <br /> osy State Mp <br /> o Contact Person Phone Number: 2( O9 1 993-7630 Fax Number: (� <br /> Arm Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: Dianothanh@yahoo.com Preferred Primary Communication:❑Mail 0 Email <br /> 11. Legal Business Owner(not progeny owner): <br /> Diana Phan (see Instructions.) <br /> Name <br /> Owner Address: 9484 West Lane Stockton CA 95210 <br /> Street City State Zp <br /> Owner Phone Number: 2(_.09 1 093-7630 Fax Number: ( <br /> Area Code Phone Number Area Code Fax Number <br /> F12. Standard Indusidal Classification(SIC)Code for the Site: 4 7 1 9 (4-Digit Number) (See instructions.) <br /> 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be, true,accurate and complete. <br /> i <br /> SIGNATURE '� J-'~� DATE 4-, „�,r�• ,,Zn �o�, <br /> NAME(print)_10 i n)A AAA.; � TITLE PHONE_qZaj- �•q 3-26 3n <br /> DISC Form 1358(6/08) <br /> TO/TO 39Vd 0d3-1VA 603 90:BT 610Z/b0130 <br />