Laserfiche WebLink
Stale 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 . 1 am applying for a new permanent California ID number as a hazardous waste : 66 Generator ❑ Transporter <br /> Reason for a new number: A. EA Never had a number B . ❑ Business moved C . 04;1owner pf, business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste other than those hag s waste Wed m 40 CFR.2� 1 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 l O 9 <br /> For existing ID number: C A <br /> ❑ 2 . 1 am updating the mailing address and/or contact information only. ENVIRONMENTAL HEALTH <br /> ❑ 3 . 1 am inactivating this ID number. DEPARTMENT <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) : Michael Corradi <br /> 7 , Site Location : 3800 Burge Road <br /> StockEn CA 95215 San Joaquin <br /> City State Zip Code County <br /> 68-0123025 <br /> 8 . (a) Federal Employer ID Number (b) CDTFA Account Number <br /> ( (b) is only required from generators of greater than 5 tons per calendar year.) <br /> 9 . Mailing Address : 3846 Burge Road <br /> So6ktin CA 95215 <br /> city State Zip Code <br /> 10 . Site Contact Person : Michael Corradi <br /> First Name Last Name <br /> Contact Person Address : 3846 Burge Road <br /> Street <br /> Stockton CA 95215 <br /> City State Zip Code <br /> Contact Person Phone Number: 2( 09 ) 931 -0140 Fax Number: U <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: Corradifrms@aol . com <br /> 11 , Legal Business Owner (not property owner) : Michael Corradi <br /> g <br /> Owner Address : <br /> 3846 Burge Road Name Stockton CA 95215 <br /> Streei09 931 -0140 City State Zip Code <br /> Owner Phone Number: L� Fax Number: (� <br /> Area Code Phone Number Area Code Fax Number <br /> 12 . Standard Industrial Classification (SIC) Code for the Site : 0 1 7 5 (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) ? iLG�GGc'� ����� '• Date <br /> 10/19/2019 <br /> Name (print) Michael Corradi Title owner Phone (209) 931 -0140 <br /> DTSC Form 1358 (06/19) <br /> Page 3 of 3 <br />