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State of California-California Environmenta ection Agency Department of Toxic Substances Control-GISS P.O. Box 806,Sacramento,CA 95812-0806 CALIFORNIA HAZARDOUS WASTE PERMANENT 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 www.hwts.dt c.ca. ov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) 6 1. 1 am applying for a new permanent California ID number as a hazardous waste: 8 Generator ❑ Transporter Reason for new number: A. 4 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 per month, call(415)495-8895 for a federal ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING ID NUMBERFor existing ID number: C A REC';"'EVNE�[) ❑ 2. 1 am updating the mailing address and/or contact information only. JUN 2 fi 2013 El3. I am inactivating this ID Number. ❑ 4. 1 am reactivating this ID Number. ENVIRONMENTA ❑ 5. 1 am changing the business name only, no ownership change. HEALTH DEPARTME T (See instructions.) 6. Site/Facility/Business Name(Include DBA): super center Mart 7. Site Location: 701 E.Dr.Martin Luther King Jr.Blvd. Street Stockton Ca 95206 San Joaquin City State Zip County 8. (a) Federal Employer ID Number srkhe100438851 (b) Board of Equalization Fee Account Number 100438851 ((b)is only required from generators of greater than 5 tons per calendar year.) (See instructions.) 9. Mailing Address: 701 E.Dr.Martin Luther King Jr Blvd Street Stockton CA 95206 City State Zip (See instructions.) 10. Site Contact Person: Swaran Chouhan First Name Last Name Contact Person Address: 1632 Paola PI Street Manteca CA 95337 City State Zip Contact Person Phone Number. 20( 9 ) 993-1298 Fax Number: (� Area Code Phone Number Area Code Fax Number Contact Person Business Email Address:chouhan_gagandeep@yahoo.com Preferred Primary Communication: 8 Mail ❑ Email (See instructions.) 11. Legal Business Owner(not property owner): Swaran Chouhan Name Owner Address: 1632 Paola PI Manteca Manteca CA 95337 Street City State Zip Owner Phone Number: 209 993-1298 Fax Number: ( Area Code Phone Number Area Code Fax Number 12. Standard Industrial Classification(SIC)Code for the Site: 5 5 4 1 (4-Digit Number) (See instructions.) 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be,/truq, accurate and complete. SIGNATURE l:/_ll' L/z :7 : DATE i 1 NAME(print) )(�//a R c� �-�0 i 1J 7TITLE/^)is/ifli-f? PHONE DTSC Form 1358(10/12)