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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 /> � <br /> El 1. 1 am applying for anew permanent California ID number as a hazardous waste;fu1 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(e)and(d)per month, please complete Form 8700-12 for a federal FPA ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number: C /S1jo <br /> ❑ 2. I am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID number. <br /> - I am reactivating this ID number. Reason(please select one): A. ❑ Verification Questionnaire B. ❑ Other <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> 6. Site/f=acility/Business Name(Include DBA): KJ�of <br /> 7. Site Location: 9 <br /> Str e <br /> Cityl /_��/;��� State Zip c-,-j6 County <br /> 8. (a) Federal Employer ID Number�{ , QST (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: f C) 1 617 _ <br /> Street <br /> q'c�- <br /> city State Zip Code <br /> 10. Site Contact Person; o'bWla('11(14rcy G) <br /> First Name Last Name <br /> Contact Person Address: _ i�, ? A 'igl dip" 1y <br /> tree � <br /> City State �Ziip Code �� <br /> Contact Person Phone Number: ( l � ) Fax Number: ) ]J li�`�— � 1/ <br /> Area Code Phone Number T Area Code Fax Number <br /> Contact Person Business Email Address: <br /> 11. Legal Business Owner(not property owner): j!f � V <br /> Name <br /> Owner Address: _ ��1� a `j qL Lie <br /> Street City State Zip Code <br /> Owner Phone Number: ( Fax Number: ( ) <br /> Area Code Phone Number Area Cade Fax Number <br /> 12. Standard Industrial Classification (SIC)Code for the Site: 3-3 (4-Digit Number) <br /> 13. Certification: 1 certify under penalty of law that the info atio or�..tFr ocum nt was prepared to the best of my knowledge and <br /> belief to be true, accurate and pleF II <br /> SIGNATURE(handwritten) Date <br /> Name(print) Title � (/'I er Phone !Y <br /> DTSC Form 1358(09/18) <br /> Page 3 of 3 <br />