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State: of California — California Environmental Protection Agency Department of Toxic Substances Control Office of Environmental Information Management PERMANENT STATE ID NUMBER APPLICATION Please type or print legibly in ink . NEW NUMBER REQUESTS Check all that apply. / V1 . 1 am applying for a new permanent California ID number as a hazardous waste : l Generator ❑ Transporter Reason for a new number: A . ❑ 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 other than those hazardous waste listed in 40 CFR 261 . 5 subparts (c) and (d) per month, please complete Form 8700- 12 for a federal EPA ID number, CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER For existing ID number: C A .A. 0 ® 4Tn 'A q �) ate' _ _ ❑ 2 . 1 am updating the mailing address and/or contact information only. ❑ 3 , 1 am inactivating this ID number. 4 . I am reactivating this ID number. Reason (please select one) : A . IK Verification Questionnaire B . ❑ Other ❑ 5 . I am changing the business name only, no ownership change . 6 . Site/Facility/Business Name ( Include DBA) : v.) t9 �~C C tA (� -t�i o PJ 7 . Site Location : l \ 1S • �1 lA. t ` � U `Q ' Street P � C�( O _ � S I � say\) k City State Zip Code County 8 . (a ) Federal Employer ID Number ( ( b) Board of Equalization Fee Account Number ( (b) is only required from generators of greater than 5 tons per calendar year.) 9 . Mailing Address : �- Street �b 96 city State Zip Code 10 . Site Contact Person : Di aria _ � ( A � 1 ` 4 K) First Name as Name rr Contact Person Address : 1 1 r LAS ` Street T� kie, nL�L City State Zip Code Contact Person Phone Number: Qci ) 361 OC96 Fax Number: ( oQ6q �o f � 20 �1-� Area Code Phone Numberrte Area Code Fax Number Contact Person Business Email Address : i c. tt✓7 U Cc, J ¢ ` 11 . Legal Business Owner (not property owner) : 10i 6 � r� 0 + U R Ny Name, Owner Address : � � S . ( 7L'Li