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2011 EPA ID NUMBER VERIFICATION QUESTIONNAIRE • Return within 30 days to avoid suspension of your EPA ID Number See Instructions on back. Please type or print clearly and use only standard abbreviations. MY MINI MART Mailing Address: If no change, please leave blank. 1756 WILSON WAY Address: STOCKTON,CA 95205-0000 City/State/Zip: DO NOT WRITE IN THIS BOX. If the information in this box is incorrect,call (877)454-4012. 1. EPA ID NUMBER: CAL000298604 SUSPENDED AS OF 6/30/2010 2. LOCATION ADDRESS: 1756 WILSON WAY STOCKTON,CA 95205-0000 In If your business has moved,a new EPA ID Number is required. See instructions on back. 3. FEDERAL EMPLOYER ID NUMBER(FEIN)REQUIRED: (Also called a Federal Tax ID.) If you do not have a Federal Employer Identification Number, please provide your Social Security Number. 4. BOARD OF EQUALIZATION NUMBER(BOE)Hazardous Waste Number: SR BH 97-156391 (HG EF 36-xxxxxx) REQUIRED ONLY IF GENERATING 5 OR MORE TONS OF HAZ WASTE PER YEAR, 5. COMPANY OWNER INFO: IMPORTANT—If you are a new owner and this is a California EPA ID Number(CAL and some CAD prefixes)that belonged to the previous owner,do not enter new information on this form. Check Box 6 to cancel this ID Number. Company Owner Info Change: If no change, please leave blank. Owner or Corp. Name: •JOGINDER LAL L] Name Change Only/No Ownership Change 1756 WILSON WAY ❑ Ownership Change` Date of Ownership Change': STOCKTON,CA 95205-0000 (209)473-0534 Address: (000)000-0000 City/State/Zip� Telephone: Fax:_ Federal EPA ID Numbers Only. California EPA ID Numbers are not transferable. 6. ❑ CHECK TO CANCEL THE EPA ID NUMBER SHOWN ON LINE 1. ID NUMBER WILL BE CANCELED EFFECTIVE 6/3012011. If you checked this box in prior year(s)and did not manifest in 2010, please contact our office. (See back for more info.) 7. COMPANY NAME: Company Name Change: If no change,please leave blank. MY MINI MART 8. CONTACT INFO: Contact Info Change: If no change, please leave blank. A14R 0kdL'A1 RQ (Y) Sa d!✓1y 17566WILWILSOONNWAWAY Name/Title: STOCKTON,CA 95205-0000 Address: (209)97.-s22" (209)941-2264 City/State/Zip: Telephone:'1 0 9—3 9 d 1 S I (a Fax: Business Email Address: 9. SIC CODE(4 digits). If printed SIC Code is incorrect, please enter correct Code. 5541 See instructions on back for SIC Code information. 10. 1 hereby certify under• penalty of perjury that the information above and on the fee forms is true and correct.Name(please print):_{(_J 11 p� d ✓vA n�A 13, Title: /)I Q n 0 q e Signature;-(i O� two.' �0._QInO^n. Date: 0 DTSC 1193(4/11) 1 22964 0/0