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la_California Environmental Protection Agency Department of Toxic Substances Control .MNMP <br /> PERMANENT STATE ID NUMBER APPLICATIONsos,Sacramento,cq ssstz-0eos <br /> Please type or neatly print in Ink. Please review the line-by-line instructions carefully. <br /> To check on the status of our"quest, o to htt :llwww.hwts.tltsc.ca. ov,and click on Reports- <br /> 7:i <br /> e orts. <br /> Fsfbp <br /> BER REQUESTS Check all that apply. (See inStmetionS.) <br /> ,: applying for a new permanent Calitomia ID numher as a hazardous waste: 16d Generator ❑Transporter <br /> } for new number A. ❑ Never had a number B. ❑ Business moved CC..`❑ Legal owner of business changed <br /> ess generates greater100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 2615 <br /> and(d),permonth,complete Form 8700-12 for an EPA(federal)ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) <br /> For existing ID number. C A <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. <br /> ❑ 4. I am reactivating this ID Number. Reason(please select one): A. ❑ Verification Questionnaire B. ❑ Other <br /> ❑ 5. 1 am changing the business name onl hip change. <br /> t II eeinstroctions.) <br /> 6. SitelFacility/Rusin (S <br /> //ess Name'(I•nduudeDBAA): 1L C Lot e A Mo 2 <br /> 7. Site Location:.ZblS L )-eQ-- 4)ta, - l r l7 Q au <br /> Str t <br /> a4L%L L-0- gS31) l s� fdgG[l/h <br /> City d state Zip county — / <br /> B.(a)Federal Employer ID Number42--S I'M 71 (b)Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater than 5 tons per calendar year.) <br /> (See instructions.) <br /> 9. Mailing Address: �6 5 "`� to r4 K I (h e �4 <br /> Sheet <br /> Ra r� rJ4- gs3oY <br /> City state Zip <br /> G <br /> 10. Site Contact Person: ! m�� ix <br /> S (See instructions.) <br /> First Name Last Nam <br /> Contact Person Address: <br /> .211 <br /> Street RALy IS3?.� - <br /> city 4 State Zip <br /> Contact Person Phone Number. ( y53 3,;7—m31 Fax Number: (_) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: LJ"J4 L 5 t�>n."Prefeaed PrimaryCommunication: ❑ Mall Email <br /> r (See instructions.) <br /> 11. Legal Business Owner(not property owner): � (a� kl V1tia 1 ' ,{/ u4--�S <br /> Owner Address:�1� l �Y'G 41� a\Q l�'1 '� �k�% C n' 9530 <br /> Street City State Zip <br /> Owner Phone Number. ( ) ,g 3]�—O'Dn Fax Number: (� <br /> Area ode Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification (SIC)Code for the Site: _ (4-Digit Number) (See instructions.) <br /> 13. Certificatio ceRity under penalty of law that!h information on this document was prepared to the best of my knowledge and <br /> belieft e,tree,au�urate and complete. u <br /> SIGNAT r ' DATE 0 <br /> /1 9 <br /> NAME(p TITLE y�/G 717 4� PHONE f.0 d) <br /> DfSC Form 1358(Otn7) , <br /> Scanned with CamScanner <br />