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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 /> p9 1 . I am applying for a new permanent California ID number as a hazardous waste : ❑ Generator ❑ 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 NUMBER <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. 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) : M I ftTAhl to O S � u �"o g e ,> 7 (l, <br /> 7 . Site Location : S I^I o /i G tzmjp* sp' /0 4 I <br /> Street <br /> Sofas FkTaAl <br /> CityState 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 : SA/%) e <br /> Street <br /> City State Zip Code <br /> 10 . Site Contact Person : C I S L9 O rl I �/a /✓ G OS <br /> First Name Last Name <br /> Contact Person Address : .S/-) M 2 <br /> Street <br /> City State Zip Code <br /> Contact Person Phone Number: ( )L19 9 ) 9 )' " g 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) : IS O G 191AI O /h JSIJ /J G O S <br /> Name <br /> Owner Address : S /4M zo <br /> Street City State Zip Code <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 : J0 (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, accurate and complete . <br /> SIGNATURE (handwritten ) '✓✓L Date <br /> Name (print) C (Z IS o G oil0 t jA 0S Title O v✓ eve^ Phone Z 9 Lf $ 1 ^ O y6 8 <br /> DTSC Form 1358 (09/18) <br /> Page 3 of 3 <br />