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State of California — California Environmental Protection Agency <br /> Dep <br /> rtment of Toxic <br /> nces Control <br /> Office of nformation Management <br /> PERMANENT STATE ID NUMBER APPLICATION <br /> NEW NUMBER REQUESTS Check all that apply. Please t e or Print le ibl in ink. <br /> ❑ 1 . I am applying for a new permanent California ID number as a hazardous waste: ❑ Generator <br /> Reason for a new number: A. ElNever <br /> caner of business changed <br /> Never had a number B . ❑ Business move <br /> W other than those hazardous waste lisd C. ❑ Legal o ❑ Transporter <br /> if your business generates greater than 900 kg of RCRA hazardous ted in 40 <br /> subparts (c) and (d) per month, please complete Form 8700- 92 for a federal EPA ID number. <br /> CFR 269. 5 <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER_ <br /> For existing ID number: C AIIIIIIIIIIs (� c) <br /> ❑ 2 . lam updating the mailing address and/or contact information only. <br /> ❑ 3 . I am inactivating this ID number. <br /> . I am reactivating this ID number. Reason (please select one) : A, <br /> El5. 1 am changing the business name only, no ownership change , ' Verification Questionnaire B. ❑ Other <br /> 6. Site/Facility/Business Name (Include DBA) : 9 <br /> 7. Site Location : D <br /> Street � � � ~ <br /> city ,q� <br /> 8. (a) Federal Employer ID Number �� ~��i ,� state Zip code <br /> (b) Board of Equalization Fee Account Number County <br /> ((b) is only required from generators of greater than 5 tons per calendar year.) <br /> 9. Mailing Address : L � CP � ( <br /> Street J— <br /> /, <br /> IIIIIIIIIIIIIIIIIh 11111 1 :1111 : CLU 11 <br /> Cit <br /> State <br /> Zi Code <br /> 10. Site Contact Person : I �� <br /> First Name _ Last Name <br /> Contact Person Address: 3 :`jt <br /> Contact Person Phone Number: grea <br /> Zip code <br /> Fax Number: :3 <br /> ode Phone Number � <br /> Area Code <br /> Contact Person Business Email Address: Fax Number <br /> 11 . Legal Business Owner (not property owner): <br /> OwnerAddress : � � N me <br /> 1 <br /> Strcc+ �7 <br /> Owner Phone Number. ) �J�q — ��/�(L City state Zipcode \J <br /> Area Code Fax Number: <br /> Phone Number Area Code <br /> Fax Number <br /> 12 . Standard Industrial Classification (SIC) Code for the Site: <br /> LZ (4-Digit Number) <br /> 13 . Certification : l certify under penalty oflaw that the inform <br /> belief to be true, accuraand mp/etion on this document was prepared to the best of <br /> te te <br /> MY knowledge and <br /> SIGNATURE (handwritten) <br /> Name (print) o; / Date <br /> i Title Phone 33 <br /> - spy <br /> DISC Form 1358 (09/18} <br /> i <br /> i <br /> I <br /> Page 3 of 3 <br /> l <br />