COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

F State of California—California Environmental Protection Agency - Department of Toxic Substances Control Office of Environmental Information Management PERMANENT STATE ID NUMBER APPLICATION Please type or print legibly in ink. NEW NUMBER REQUESTS Check all that apply. ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter Reason for a 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 other than those hazardous waste listed in 40 CFR 261.5 subparts(c)and(d)permonth,please complete Form 8700-12 fora federal EPA ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER For existing ID number: C A _ 0 0 U 1 S- -7 ❑ 2. 1 am updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID number. 1�4. I am reactivating this ID number. Reason (please select one): A. Verification Questionnaire B. ❑ Other ❑ 5. 1 am changing the business name only, no ownership change. g� 6. Site/Facility/Business Name(Include DBA): (/U�l�y L r M r /LJ (Jg i�r�•(jol�3 V'✓ 'y��.t?� r r 7. Site Location: Street r i2- `10 SAA �AIVU i A✓ � City ` Cr State Zip Code County !� 8.(a)Federal Employer ID Number'I/ QC� /r (b)Board of Equalization Fee Account Number ((b)is only required from generators of greater than 5 tons per calendar year.) 9. Mailing Address: ( VV/'/lll'NifiSTq� l� Street tot `�V C�T ! 52- cityC•C State —1— T Zip Code 10. Site Contact Person: 71�>O First Name Last Name Contact Person Address: Wa'R.° 71MS'i by/4 StreetI 4215 I } Gr. `Z'IC ' City { � State aZip Code�+ Contact Person Phone Number: J�) jt0� �-1� 'y Fax Number: (, ) J&5 Area Code Phone Number- , Area Code Fax Number Contact Person Business Email Address: �JL7� ��f�l��• COM p L 11. Legal Business Owner(not property owner): Name Owner Address: (,r4 ,T4✓944y-,p l &V) 6 15? VQ Street . A City State Owner Phone Number: © /) .�(a� %�Ej Fax Number: ,5 Area Cade Phone Number Area Code Fax Number 12. Standard Industrial Classification (SIC)Code for the Site: '(4-Digit Number) IIF 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 comp ate. p_ J SIGNATURE(handwritten-)t--r(i'�' +�� Date y�/3 �7� Name(print) .-J.�Ir✓c 14x)P Title�7�Gl�+'fWIQAJj fyf tyU l�.� Phone CnA�I% �."i5 f��03 i DTSC Form 1358(09/18) Page 3 of 3 I