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f q03 46 <br />State of California — California Environmev i tection Agency atpartment of Toxic Substances Control - GISS <br />P.O. Box 806, Sacramento, CA 95812-0806 <br />nu as .L. CA <br />CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br />Please type or neatly print in ink. Please review the line -by-line instructions carefully. <br />To check on the status of your request, go to www.hwts.dtsc.ca.gov and click on Reports <br />NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br />❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter <br />Reason for 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 per month, call (415) 495-8895 for a federal ID number. <br />CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER (See instructions.) <br />For existing ID number: C A <br />❑ 2. 1 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 />6. Site/Facility/Business Name (Include DBA): <br />7. Site Location: <br />Street <br />(See instructions.) <br />City State Zip County <br />8. (a) Federal Employer ID Number (b) Board of Equalization Fee Account Number <br />((b) is only required from generators of greater than 5 tons per calendar year.) <br />(See instructions.) <br />9. Mailing Address: <br />Street <br />City State Zip <br />10. Site Contact Person: <br />Contact Person Address: <br />First Name <br />City <br />Last Name <br />State <br />Zip <br />(See instructions.) <br />Contact Person Phone Number: ( ) Fax Number: () <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business Email Address: Preferred Primary Communication: ❑ Mail o Email <br />(See instructions.) <br />11. Legal Business Owner (not property owner): <br />Name <br />Owner Address: <br />Street City State Zip <br />Owner Phone Number: ( Fax Number: ( ) <br />Area Code Phone Number Area Code Fax Number <br />12. Standard Industrial Classification (SIC) Code for the Site: _ (4 -Digit Number) (See instructions.) <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. <br />SIGNATURE DA <br />NAME (print) <br />DTSC Form 1358 (10/12) <br />PHONE <br />