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State of California-California Environmental Protection Agency Department of Toxic Substances Control <br /> Office of Environmental Information Management <br /> PERMANENT STATE ID NUMBER APPLICATION <br /> Please type or print legibly in ink. <br /> NEW NUMBER REQUESTS Check all that apply. <br /> ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter <br /> Reason for a new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br /> if your business generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261.5 <br /> subparts(c) and(d)per month, please complete Form 8700-12 for a federal EPA ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number: C A Q -L 0 -�i 1 3 '� 74 Cf <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID number. <br /> .91",-4. 1 am reactivating this ID number. Reason (please select one): A.-4A Verification Questionnaire B. ❑ Other <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> 6. Site/Facility/Business Name(Include DBA): <br /> 7. Site Location: ( (-)0-q W v� cjS�rr ti e �I . <br /> Street <br /> rM CX fy1F e C cn r dl 33 >C. Sc-)CA Q v'i V1 <br /> City State Zip Code County T <br /> 8. (a) Federal Employer ID Number5t,-` (b) Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> 9. Mailing Address: <br /> Street <br /> c�v�4ec c� C'If) ('-334 <br /> city State Zip Code <br /> 10. Site Contact Person: C1 CN( CA CA <br /> First Name Last Name <br /> Contact Person Address: SL1�Cl <br /> Street <br /> YV1C�ll��CCr ��, <br /> City �1 State Zip Code <br /> Contact Person Phone Number: (ICE) ',�_�1;7 � � Q ') Fax Number: (� <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: A • ''A17%'j 1: ti • t o:✓L <br /> 11. Legal Business Owner(not property owner): �_AL1+1 eA L1(.\C C-+,M <br /> �� ` Name T r <br /> Owner Address: l h1���`I ;L4 -20fl�'C <br /> - 9 fyta" C L 1 ��S 7 L <br /> Street n City State Zip Code <br /> Owner Phone Number; (mi G �'1 G j Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: (4-Digit Number) <br /> 13. Certification: 1 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. l <br /> SIGNATURE'(handwritten) �'r7 ( ✓ r9/ f %�' _ Date I <br /> Name(print) �J(ti�tY� ��GAf (.1iCAs Title L� '�'y1�� PhoneCQYJ f L�J <br /> DTSC Form 1358(09118) <br /> Page 3 of 3 <br />