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State of California - California Environmental Protection Agency Department of Toxic Substances Control - HWMP P . O. Box 806, Sacramento , CA 95812-0806 PERMANENT STATE ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line-by-line instructions carefully. To check on the status of your request, go to htt ://www, hwts . dtsc . ca . oy 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 Be ❑ 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, complete Form 870042 for an EPA (federal) ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) For existing ID number: C A L D Q _ 3 .L Q ❑ 2 . 1 am updating the mailing address and /or contact information only. ❑ 3 . 1 am inactivating this ID Number, 4 . 1 am reactivating this ID Number. Reason (please select one) : A. ❑ Verification Questionnaire Be Other ❑ 5 . I am changing the business name only, no ownership change . (See instructions.) 6 . Site/Facility/Business Name (Include DBA) : 7 . Site Location : dJ 'Tp C (..roc Q 4 �1 Street O (.�(iCA 5 City �j State Zip Count 8 . (a ) Federal Employer ID Number l - 3o (b) Board of Equalization Fee Account Number y ( (b) is only required from generators of greater than 5 tons per calendar year.) 334 L � C j ie (� SL (See instructions.) 9 . Mailing Address : -�(' f7� I _ Street i f) See City State Zip _ (See instructions.) 10 . Site Contact Person : (,iJ�� L C First Name Last Name L� Contact Person Address : r3q G Lycke keo 4 Street Lb&U Cf� 5 16 City State Zip Contact Person Phone Number: (0) )3t ( eme 5 � Fax Number: �) Area Code Phone Number Area Code Fax Number //�� ()U' fl Dot . Cm VI" Contact Person Business Email Address : &I' di2i ( Q ( 1 bi\ , Preferred Primary Communication : Mail ❑ Email (See instructions.) 11 . Legal Business Owner (not pro 'per'ty owner) : i � Vr l V� Owner Address : � `T �i I.LJm r� p q I �-1V Stree City State . /I Zip `Y Owner Phone Number: (�U"1 ) >34 — JK� � Fax Number: (�) 3 '3 �J �� Area Code Phone Number Area Code Fax Number F12 . Standard Industrial Classification (SIC ) Code for the Site : (4- Digit Number) (See instructions.) 13 . Certification : / certify under penalt of law that the information on this document was prepared to the best of my knowledge and belief to be, tru accurate and mplete. Q d SIGNATURE DATE U 0 NAME (print) �) Wr/ iL�1 TITLE �� 4� PHONE i DTSC Form 1358 (01 /17)