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State of California — California En ironmental Protection Agency Department of Toxic Substances Control - HWMP <br />P.O. Box 806, Sacramento, CA 95812-0806 <br />PERMANENT STATE ID NUMBER APPLICATION <br />Please type or neatly prin: in ink. Please revvsew the line -by-line instructions carefully. <br />lo cneck on the status of your request go to httP://www.11wts.dtsc-ca.-qov and click on Reports. <br />NEW NUMBER REQUESTS Check all that apply. I (See instructions.) <br />E:11. 1 am applying for a ne permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter <br />Reason for new number: A. L7 -Never had a number B. 11 Business moved C. E. Legal owner of business changed <br />If your business generates gr ter 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, complete Form 8700-12 for an EPA (federal) ID number <br />CHANGES TO STATUS ORI FORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) <br />r existing ID number: C L 0 0 0 3 6 6 5 4 0 <br />iJ 2. 1 am updating the maili address and/or contact information only. <br />Ci 3. 1 am inactivating this ID Number. <br />4. 1 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/Facility/Business Name (Include DBA): <br />B & B Tires and Auto Service Inc (See instructions.) <br />7. Site Location: 39 N. CIIUff Ave Suite D <br />Loditreet CA 95240 Sari Joaquin <br />City <br /> State Zip Cokt�1 y <br />8. (a) Federal Employer ID Nu ler (b) Board of Equalization Fee Account NumberlV�A <br />((b) is only required from generators of greater than 5 tons per calendar year.) <br />9. Mailing Address: <br />same as above (See instructions.) <br />Street -Q <br />City State Zip <br />10. Site Contact Person: L. ret DeBerry Nit <br />(See instructions.) <br />first Name Last Name ENViROJMENTP& <br />Contact Person Address: 9 N. Cluff Ave Suite D HEALTH DF°l\rT11`'1IT <br />IT <br />ca 95240 <br />ity State Zip <br />Contact Person Phone Num er. (209) 339-1916 Fax Number: (209} 339-1912 <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business E ail Address: fixitatbandb@yahoo.com Preferred Primary Communication Mail r Email <br />11. Legal Business Owner (not operty owner) <br />L. Bret DeBerry (See instructions.) <br />Owner Address 39 N. luff Ave Sdffd Lodi CA 95240 <br />Stre City State 70Owner Phone Number: (Og) 339-1916 Fax Number:2( 09 ) 339-1912 <br />Area Code Phone Number Area Code Fax Number <br />12. Standard Industrial Classifi tion (SIC) Code for the Site: 7 5 3 8 (4 -Digit Number) (See instructions.) <br />13. Certification: I certify under enalty of law that the information on this document was prepared to the best of my knowledge and <br />belief to be, tru , accurate a d let <br />e. <br />DATE 8/23/1 8 <br />.:AME (print) L Bret DeBerry TITLE Own <br />DTSC Form 1358 (01117) - <br />PHONE 209 339-1916 <br />