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C xj ice• State of Cal'rfomia-Califomia Environmental Protection Agency Department of Toxic Substances Control a O 0 �. <br /> Office of Environmental Information Management3 <br /> O ID <br /> r PERMANENT STATE ID NUMBER APPLICATION ,^* <br /> Please or riot le ibl in ink. <br /> 1 n, <br /> � <br /> NEW Q W NUMBER RE UESTS Check all that apply. <br /> r+• <br /> applying for anew permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter <br /> C4 Reason for a new number. A.X 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 fisted in 40 CFR 261.5 <br /> (D O subparts(c)and(d)per month,please complete Form 8700.12 for a federal EPA ID number. <br /> Q CHA=ne <br /> STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> ~ For number: C A �• 0 Q�,.1 3 -s-Z <br /> P ❑ ating the mailing address and/or contact information only. <br /> ❑ ctivating this ID number-❑ ctivating this ID number. Reason(please select one): A. ❑ Verification Questionnaire B. ❑ Other <br /> ❑ nging the business name only,no ownership change. <br /> O � <br /> LFederal <br /> ss Name(include DBA):�wf M(7n I?� ,/ <br /> in <br /> 3T3l ��t���-�� �g"y in y; <br /> street <br /> SToceraN �A 9�ao� �a�✓`�AQ�/ 0) <br /> `� State <br /> Zip Code County 3 v <br /> �•'• C/1 er ID Number&8 O/lOSa T (b)Board of Equalization Fee Account Number O D <br /> ((b)is only required hom generators of greater than 5 tons per calendar yeas) p <br /> O O <br /> C 9. Mailing Address: /`�7 ���L-G�ti �� 9•gy 'n O A <br /> Street 7/Uf- Af 9 O N pQj <br /> ".S' rn �. C* state z" code n O 77 <br /> I--I CD <br /> CA � � O <br /> Q <br /> 10. Site Contact Person: La O <br /> r Fes„, First Name Last Name <br /> n OO <br /> C) <br /> Contact Person Address: 7 /% Z) ��LJF O <br /> Street 95�21% N <br /> N O City State Zip Code l0to <br /> µ.l LID <br /> V Contact Person Phone Number. (41177 !O 3y'3a J�_Fax Number. a�,d `�'(.0�' 06 J9 3 <br /> Area Code PhoneMNumber Area Code Fax Number <br /> Contact Person Business Email Address: /// r CU (D n <br /> -1 CD Q O <br /> ° CD ( p peri ) � ��5 zl�� I SRA/K A l oo�c <br /> 11. Legal Business Owner not ro owner <br /> Name (D <br /> Owner Address: <br /> Street City State Zip Code r-r <br /> Owner Phone Number: ( ) Fax Number. (� (/1 <br /> �j Area Code Phone Number Area Code Fax Number <br /> (D <br /> (D <br /> 12. Standard Industrial Classification(SIC)Code for the Site: (4-Digit Number) <br /> 7 <br /> `ry C71 13. Certification:I certify under penalty of law that the information on this document was prepared to the best of my knowledge and C <br /> ' belief to be true,accurate a7 comp) 3 <br /> SIGNATURE 1 n� n� Date 4-13 I <br /> /g\ <br /> --' Name(print /ii�N/ N/w&cc Idled&A�5L>>te-�,9L hone ! 775 1 27_9, <br /> (D <br /> DTSC Form 1358(09/18) O <br /> ¢ <br /> Page 3of3 <br /> O � <br /> (D <br /> O in <br /> 0 <br />