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NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> Q 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator Transporter <br /> Reason for new number. A. n Never had a number B. El Business moved C. ✓❑ Legal owner of business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal ID number <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br /> For existing ID number. CA L 0 0 0 2 8 6 2 3 4 <br /> 2. I am updating the mailing address and/or contact information only. <br /> 3. 1 am inactivating this ID Number. <br /> ❑� 4. 1 am reactivating this ID Number. <br /> 5. 1 am changing the business name only, no ownership change. <br /> (See instructions.) <br /> 6. SitelFacility/B e (include DBA): EXPRESS MARKET <br /> ! 7L8 (a)'F�eral <br /> Sie Location: 419 S. MAIN STREET <br /> Street CA 95337 SAN JOQUIN <br /> MANTECA <br /> cit State Zip County <br /> liz <br /> Employer ID Number 68 0425778 e Account Number <br /> ((b)is only requirerd of dfromaon ge generators of greater than 5 tons per calendar year.) <br /> (See instructions.) <br /> 9. Mailing Address: 419 S. MAIN STREET <br /> Street CA 95337 <br /> MANTECA <br /> City State Zip <br /> 10. Site Contact Person: KULJIT <br /> MANGAT (See instructions.) <br /> First Name Last Name <br /> Contact Person Address: 662 CLAY WAY <br /> Street <br /> RIPON CA 95366 <br /> City Stale Zip <br /> Contact Person Phone Number. L209 401-5292 Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: <br /> expressmarket@comcast.net Preferred Primary Communication: Mail ❑� Email <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): KULJIT MANGAT <br /> Name CA 95366 <br /> Owner Address: 662 CLAY WAY RIPON <br /> Street city slate ZIP <br /> Owner Phone Number: 2( 09 ) 401-5292 Fax Number: L_) <br /> Area Code Phone Number Area Code Fax Number <br /> 12 Standard Industrial Classification(SIC)Code for the Site: 5 5 4 1 (4-Digit Number) (See instructions., <br /> 13. Certification: I 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, accu�ratt q and complete. Mf // <br /> SIGNATURE �( Ch ) I/ ` DATE <br /> T <br /> NAME(print)X f � TITLEIi'' � PHONES�� <br /> �ng <br />