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Slate of California-California Environmental Protection Agency Department of Toxic Substances Control-GISS P.O.Box 808,Sacramento,CA 95812-0806 CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line-by-line Instructions carefully. To check on the status of your request,oo to and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) ❑ L I am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter Reason for new number. A_ ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste per month, call(415)495-8895 for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) For existing ID number: C A_ _ _ _ El2. 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. lam changing the business name only,no ownership change. (See instructions.) 6. Site/Facility/Business Name(Include DBA). 7. Site Location: Street CRY State Zip County 8.(a)Federal Employer ID Number (b) Board of Equalization Fee Account Number ((b)is only required from generators of greater than 5 tons per calendar year) (See instructions.) 9. Mailing Address: Street City State Zip (See instructions.) 10. Site Contact Person. First Name Last Name Contact Person Address: Street City State Zip Contact Person Phone Number: Fax Number (� Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: Preferred Primary Communication: ❑ Mail ❑ Email (See instructions.) 11. Legal Business Owner(not property ower): Name Owner Address. ` Street City state ZIP Owner Phone Number: (—) Fax Number: (� Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: _ (4-Digit Number) (See Instructions.) 13. Certification: l certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be, true, accurate and complete. SIGNATURE DATE NAME(print) TITLE PHONE DTSC Form 1358(10/12)