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"CKMAPICN 10 1 A I C I V N%JmDLR Nrr'-"1�m r IVr\ <br /> Pie ape or neatly print in ink. Please review the fine-by-line it ions carefully. <br /> To check on_..status of your request,go to htt :11www.hwts.dtsc.ca. and click on Reports. <br /> NEW NUMBER REQUESTS Check all that apply. (See instructions.) <br /> M 1. 1 am applying for a new permanent California ID number as a hazardous waste: 171 Generator ❑Transporter <br /> Reason for new number: A. ❑ Never had a number B. 0 Business moved C. ❑ Legal owner of business changed <br /> If your business generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261.5 <br /> subparts(c)and(d),per month,complete Form 9700-12 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. CA L 0 0 0 4 1 8 5 6 6 <br /> 0 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. <br /> 0 4. 1 am reactivating this ID Number. Reason(please select one): A. ❑ Verification Questionnaire B. ❑ Other <br /> ❑ 5. 1 am changing the business name only,no change. <br /> 6. Site/Facility/Business Name(Include DBA): <br /> FULL SERIVE CAR WASH AND LUBE (See instructions.) <br /> 7. Site Location: 2615 WEST GRANT LINE ROAD <br /> TRACY CA 95304 SAN JOAQUIN <br /> city State Zip co /01698220 <br /> 8. (a)Federal Employer ID Number94-3268396 (b)Board of Equalization Fee Account Number <br /> ((b)is only required from generators of greater then 5 tons percelandar year) <br /> 9. Mailing Address: <br /> 2615 WEST GRANT LINE ROAD (See instructions.) <br /> Street CA 95304 <br /> TRACY <br /> city State zip <br /> (See instructions.) <br /> 10. Site Contact Person: WAIS HAKIMI <br /> First Name Last Nene <br /> Contact Person Address: 2119 FRANK BLONDIN LI <br /> ICY CA 95377 <br /> City State zip <br /> Contact Person Phone Number: 91 25 ) 339-0039 Fax Number: (� <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address:WNYGLS@YAHOO.COM Preferred Primary Communication: o Mall to Email <br /> (See instructions) <br /> 11. Legal Business Owner(not property owner): <br /> VIKAS PATEL <br /> OwnerAddress: 2615 WEST GRANlNCNE ROAD TRACY CA 95304 <br /> Street <br /> t572 4837 city state Zip <br /> Owner Phone Number (_) Fax Number: (� <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the site: 7 5 3 8 (4-Digit Number) (See instmctions.) <br /> 13. Certification: I certify�uy ,penalty of law that the information this document was prepared to the best of my knowledge and <br /> belief to be,true,a eLrate and cont, late. <br /> SIGNADATE 02.26.18 <br /> NAME(print) WAIS AKIMI TITLE OWNER PHONE 925-3390039 <br /> DTSC Form 1358(01/17) <br /> 'CCEIVEp <br /> NrR 0 2018 <br /> 1 E"`f'r`^�'r�IvfENT <br /> D`nA,9TA ENT <br />