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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 /> 1 . I am applying for anew 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, El Legal owner of business changed <br /> If your bus/ness generates greater than 100 kg of RCRA hazardous waste other than those h ds 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. c K' . <br /> �I <br /> S _ ry , <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number: C A � �0 .0 .Q i ) R K 2018 <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> X3 . 1 am inactivating this ID number. <br /> ❑ A . I am reactivating this ID number. Reason ( please select one) : A. ❑ Verification Questionnai , 3 <br /> ) I � <br /> El 5s I am changing the business name only, no ownership change. tMNz SRI . <br /> 8. Site/Facility/Business Name ( Include 06A): i V o cA bm , Oz Lwdo ?ou Pr AaQba, 16.flS 'w, <br /> Q <br /> 7. Site Location: �2:7 q5 Li <br /> tit <br /> City /� State Zip Code County <br /> 8. (a) Federal Employer ID Number1�) " r3d 12 (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: 1 t� � 1i Y_ 1f�^M.�r(X1 5 ( 4 s <br /> Sir et § <br /> � _ : OA <br /> City State Zip Code <br /> t <br /> t � i <br /> 10 . Site Contact Person: ' Y5 i lU4 !SayicIr <br /> First Name Last dame(( <br /> Contact Person Address: 5: <br /> Stre t <br /> City State Zip Code <br /> Contact Person Phone Number: { TLei ) Fax Number: "? w s " "7 l0q3 <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: I <br /> i <br /> 11 . Legal Business Owner (not property owner) : CX <br /> Is NA <br /> Name <br /> Owner Address: <br /> S reeL City State Zip Code <br /> Owner Phone Number: Al i } _ �� — (Jt3ilsssl Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> 12 . Standard Industrial Classification (SIC) Code for the Site: `? (4-Dlglt Number) <br /> 13, Certification: I certify under penalty of law that the Int ation o this d ument was prepared to the best of my knowledge and <br /> belief to be true, accurate ar) ee /ete. <br /> SIGNATURE (handwrit ( Date 1 z, <br /> Name (print) e &PAM <br /> Phone <br /> DTSC Form 1358 (09/18) <br /> Page 3 of 3 <br />