Laserfiche WebLink
P-tection Agency -Department of Toxic Substances Control-GISS <br /> State of California-California Environmental 9 Y D. Box 806,Sacramento, CA 95812-0806 <br /> CALIFORNIA HAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION <br /> Please type Or neatly print in ink. Please review the line-by-line instructions carefully. <br /> To check on the status of your request,go to www hwts dtsc.ca.gov and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter <br /> Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste per month, contact US EPA for a federal IDD number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBER e <br /> For existing ID number: C A L 0 0 0 3 6 5 2 7 7 <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. DEC 0 12014 <br /> ■ 3. 1 am inactivating this ID Number. <br /> ❑ 4. 1 am reactivating this 1D Number. ENVIRONMENTAL HEALT <br /> ❑ 5. 1 am changing the business name only, no ownership change. DEPARTMENT <br /> (See instructions.) <br /> 6. Site/Facility/Business Name (Include DBA): Wheel Works#8249 _ <br /> 7. Site Location: 420 West Lodi Avenue <br /> Street <br /> Lodi CA 95240 San Joaquin County <br /> City State Zip County <br /> 8.(a) Federal Employer ID Number (b) Board of Equalization Fee Account Number 42-138983 <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> (See instructions.) <br /> 9. Mailing Address: 333 East Lake Street Attn: Karen Moecker-BSRO <br /> Street <br /> Bloomingdale Illinois 60108 <br /> City State Zip <br /> (See instructions.) <br /> 10. Site Contact Person: Karen Moecker-BSRO <br /> First Name Last Name <br /> Contact Person Address: 333 East Lake Street <br /> Street <br /> Bloomingdale Illinois 60108 <br /> City State Zip <br /> Contact Person Phone Number. ( 630 1 259-9216 _ Fax Number:j 630 ) 672-1382 <br /> Area ode Phone Number Area Code Fax Number <br /> Contact Person Business Email Address:_enygen(abfrc.com Preferred Primary Communication: ❑Mail ■Email <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): Bridgestone Retail Operations LLC <br /> Name <br /> Owner Address: 333 East Lake Street Bloomingdale Illinois 60108 <br /> Street City State Zip <br /> Owner Phone Number: ( 630 ) 259-9000 Fax Number: ( 630 1 259-9383 <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification (SIC)Code for the Site: 5 5 3 1 (4-Digit Number) (See instructions.) <br /> 13. Certification: /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 5V)2aLdAzA ��� DATE 11/26/2014 <br /> NAME(print) Karen Moecker TITLE Retail Environmental Specialist PHONE (630)259-9216 <br /> DTSC Form 1358(6/08) <br /> BSRO PIN#177040-255638-8249 <br />