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Permanent State ID Number Application <br /> DTSC Form 1358 (Revision 05/20) Page 2 of 2 <br /> 10. Site Contact Person: Gz-i I b-QA- <br /> First and Last Name <br /> Contact Person's Address: ` soncra <br /> Str.et <br /> sbck-kr-�, bo- 9905 <br /> City State ZIP Code <br /> Contact Person's Phone Number: anq) <br /> Area Code Phone Number Extension <br /> Fax Number:!�A) V�(o <br /> Area Code Fax Number <br /> Contact Person's Business Email Address: 3 Y1r�(� G' ?1 C :A 3ln_.)(� <br /> 11. Legal Business Owner (not property owner): �(J C,�r WC ��\ <br /> First and Last Name <br /> Owner's Address: <br /> Street <br /> CJL6 <br /> City State ZIP Code <br /> Owner's Phone Number:aff ) ! q7-1 <br /> L <br /> Area Code Phone Number Extension <br /> Fax Number: p ) /, L — llfJ <br /> Area Code Fax Number <br /> 12. Standard Industrial Classification (SIC) Code for the Site (4-digit number): 77 l <br /> (o- <br /> 13. Certification: I certify under penalty of law that the information on this document was <br /> prepared to the best of my knowledge and belief to be true, accurate and complete. <br /> Signature (handwritten): - Date: <br /> Name (print): Title: Phone: <br />