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it <br /> State of California — California Environmental Protection Agency Department of Toxic Substances Control <br /> Office of Environmental Information . Management <br /> ` PERMANENT STATE ID NUMBER APPLICATION <br /> Please type or print le ibl in ink . <br /> NEW NUMBER REQUESTS Check all that apply. <br /> C7 1 . I am applying for a new permanent California ID number as a hazardous waste : Generator ❑ Transporter <br /> Reason for a 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 other than those hazardous waste listed in 40 CFR 261 . 5 <br /> subparts (c) and (d) per month, please complete Form 870042 for a federal EPA ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMB <br /> WD <br /> 72 , <br /> isting ID number: C A C7 � � � a <br /> 1 am updating the mailing address and/or contact information only. <br /> ❑ 3 . 1 am inactivating this ID number. <br /> ele'4 . I am reactivating this ID number. Reason (please select one) : A. ❑ Verification Questionnaire B . ❑7Other <br /> ❑ 5 . 1 am changing the business name only, no ownership change . <br /> 6 . Site/ Facility/Business Name ( Include DBA) : ���� <br /> 7 . Site Location : N <br /> Street � 5 ?ooq <br /> City h � � State Zip Code Com <br /> 8 . (a ) Federal Employer ID Number 20 -� l �, dd �S (b ) CDTFA Account Number <br /> ( (b) is only required from generators of greater than 5 tons per calendar year. ) <br /> 1v <br /> 9 , Mailing Address : ` <br /> Cityty State Zip Code <br /> 10 . Site Contact Person : <br /> First Name L st�Naame <br /> Contact Person Address . S'- <br /> �tr6T <br /> City , State Zip Code <br /> Contact Person Phone Number: (��) J \ '� L ✓ Fax Number : ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> . � �4' 1 <br /> Contact Person Business Email Address : <br /> 11 . Legal Business Owner (not property owner) : <br /> me <br /> � r <br /> Owner Address : C7 <br /> Street City State Zip Code <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 : _ — _ _ (4-Digit Number) <br /> 13 . Certification : I 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 an complete. <br /> SIGNATURE (handwritten ) Date 01 _l A— <br /> Name ( print ) Title f� Phone � <br /> DTSC Form 1358 ( 06/ 19 ) <br /> Page 3 of 3 <br />