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State of California—California Envirpnmenta ?ction Agency rtment of Toxic Substances Control -HW MP 0.Box 806,Sacramento,CA 95812-0806 PERMANENT STATE ID NUMBER APPLICATION Ple�se type or neatly print in ink. Please review the line-by-line instructions carefully. To check on the status of your request,go to www.hwts.dtsc.ca. ov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter Reason for new number. A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261.5 subparts(c)and(d),per month, omplete Form 8700-12 for an EPA(federal)ID number. CHANGES TO STATUS OR INgORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) For existing ID number: C A L 0 0 0 _2 9 8 A 7 6 ❑ 2. 1 am updating the mail ng address and/or contact information only. ❑ 11 am inactivating this ID number. ❑p 4. 1 am reactivating this ID Number. ❑ 5. 1 am changing the business name only, no ownership change. i (See instructions.) 6. Site/Facility/Business Name(Include DBA): SB Gas & Market 7. Site Location: 515 W 11th St Street Tracv CA 95376 San-Joaquin City State Zip County 8. (a)Federal Employer ID Number 20-3804724 (b)Board of Equalization Fee Account Number ((b)is only required from generators of greater than 5 tons per calendar year.) (See instructions.) 9. Mailing Address: 515 W 11th St Street Tracy CA 95376 city State Zip (See instructions.) 10. Site Contact Per4on: Ken Cook I First Name Last Name Contact Person Address: 515 W 11th St Street Tracy CA 95376 city State Zip Contact Personhone Nu ber. (209)834-8838 Fax Number. ( ) Area Code Phone Number Area Code Fax Number Contact Person:usinessmail Address: SbgaSandmarket(@Vahoo.Com Preferred Primary Commu kation: ❑■ Mail ❑ Email (See instructions.) 11. Legal Business Owner(not property owner): Sanjay Birla First Name Last Name Owner Address: 5151AIllthSt Street Tracy CA 95376 City State Zip Owner Phone Number. 510 414-5390 Fax Number. ( } AreE Code Phone Number Area Code Fax Number (See instructions.) 12. Standard Industrial Classiri tion(SIC)Code for the Site: 5 4 1 1 (4-Digit Number) ( eW7nstrutions.) 13. Certification: I certify and r penalty of law that the information on this document was prepared to the best of my knowledge and belief to be,true,accurate and comple0te. —7 2 SIGNATURE ( � DATE / �� 3 _ NAME(print) Ke COOk TITLE Manager PHONE (209) 834-8838 DTSC 1358(5/29/15)