Laserfiche WebLink
Permanent State ID Number Application <br /> DTSC Form 1358 (Revision 05/20) Page 2 of 2 <br /> i <br /> 10. Site Contact Person: --To- L4p,s-c-7,) <br /> First and Last Name <br /> Contact Person's Address: 7P6 R6,4 lee <br /> Street <br /> i <br /> City State ZIP Code <br /> Contact Person's Phone Number: 72s--/ ,yYP X 7CS"/ <br /> Area Code Phone Number Extension <br /> Fax Number: ( 66 ( ) ,37-- ID-3/ <br /> Area Code Fax Number <br /> Contact Person's Business Email Address: Jo MLj,1 te, --Faf-Ms , cc <br /> 11. Legal Business Owner (not property owner): kc-b Ie- L131) rl ae r <br /> First and Last Name <br /> Owner's Address: 79 E c a-,] 1 , <br /> Street <br /> �cL*/-uLj C A c?32 i.S <br /> City State ZIP Code <br /> Owner's Phone Number: 72-5 - E. c/SV <br /> Area Code Phone Number Extension <br /> Fax Number: ( 661 ) 721 - 2- / 3`f <br /> Area Code Fax Number <br /> 12. Standard Industrial Classification (SIC) Code for the Site (4-digit number): / <br /> 13. Certification: I certify under penalty of law that the information on this document was <br /> prepared to the best of my knowledge and belief to be true, accurate and complete. <br /> Signature (handwritten): 55;�_z 7L_ _� - - Date: <br /> Name (print): J_c#n L;.¢2s6;;u Title: 7�-c-+t Phone: SLs-.Sys? <br />