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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 /> El 1. I am applying for a new permanent California ID number as a hazardous waste: Generator El 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 NUMB <br /> For existing ID number: C ACIL_ <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. 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): i 0 AWAy (gyp <br /> 7. Site Location: SXeet <br /> City State Zip Code 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 /> 9. Mailing Address: <br /> Street <br /> City I State Zip Code <br /> 10. Site Contact Person: b y __. 1)01)ma� <br /> First Name Last Name <br /> Contact Person Address: <br /> treet <br /> City State Zip Code i <br /> Contact Person Phone Number:79q Fax Number: ) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: <br /> 11. Legal Business Owner(not property owner): <br /> Owner Address: <br /> tr(pt ) j`�ys�` � City ( j tate —i _Zip .ode <br /> Owner Phone Number: � �„` (��J Fax Number. 1 <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: 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, accuraO and complete. <br /> SIGNATURE (handwritten) Date <br /> Name (print) WN " -C111 Title Phone <br /> DTSC Form 1358(09/18) <br /> Page 3 of 3 <br />