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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: <br />G::'11 [ �, b-Q�,� <br />First and Last Name <br />Contact Person's Address:` soncra S4-- <br />City <br />Contact Person's Phone Number: ( ) <br />Area Cod <br />Fax Number:!�A) <br />Area Code <br />e <br />State ZIP Code <br />W7— / t <br />Phone Number Extension <br />Y�(0 <br />Fax Number <br />k <br />Contact Person's Business Email Address: \ Y1r�(� <br />11. Legal Business Owner (not property owner): <br />Owner's Address <br />Street <br />I d t 101,E C\O'/', <br />First and Last Name <br />2J- <br />CJL6 Ur-� dao 3 <br />City <br />Owner's Phone Number: ) <br />Area Code <br />Fax Number: ) <br />Area Code <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 />State ZIP Code <br />Cf <br />Phone Number <br />Extension <br />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 />