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State<)f California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Office of Environmental Information Management <br /> PERMANENT STATE ID NUMBER APPLICATION <br /> Please t— or rint le ibl in ink. <br /> NEW NUMBER REQUESTS Check all that apply. <br /> ❑ 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 /> rexisting <br /> STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> number: CA <br /> dating the mailing address and/or contact information only. <br /> ctivating this ID number. <br /> 4. 1 am reactivating this ID number. Reason (please select one): A. ,91 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 /> 7. Site Location: / D ! K <br /> Stree <br /> zyv® l � <br /> City �-��p��State Zip Code County <br /> 8. (a)Federal Employer ID Numberly a� (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: 17xa �yj �— <br /> Street <br /> City C State Zi Code <br /> 10. Site Contact Person: <br /> First Name Last Name <br /> &ZA7— <br /> Contact Person Address: <br /> Stree c'�l <br /> City State Zip Code <br /> Contact Person Phone Number: ) ��z��// Fax Number: O G� <br /> Area Code Phone Number Area Code Fax Number' <br /> Contact Person Business Email Address: ® eere, <br /> 11. Legal Business Owner(not property owner): -ILZOv weer- <br /> Owner Address: _Zzye0 �rl�u/ lela <br /> Street City r State Zip Code <br /> Owner Phone Number: ("O") �.�'�`�l�G Fax Number: (Qw, <br /> Area Code Phone Number Area ode Fax Number <br /> F12. Standard Industrial Classification(SIC)Code for the Site: (4-Digit Number) <br /> 13. Certification: /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 te. <br /> SIGNATURE(handwritten Date '�� <br /> Name(print) Q Title hone p;1;r_a 17 <br /> DTSC Form 1358(09/18) <br /> Page 3 of 3 <br />