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State of California-California Environmental Protection Agency Department of Toxic Substances Control -FlWMP P.O.Box 806,Sacramento,CA 95812-0806 PERMANENT STATE 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,22 to&)vw.hwts.dtsc.2j.W_v and click on Reports. NEW NUMBER_REQUESTS Check all that apply. (See instructions.) ❑ 1. 1 am applying for a new permanent Callfomia ID number as a hazardous waste: 0 Generator 0 Transporter Reason for new number: A. 171 Never had a number B. [] Business moved C. 171 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,complete Form 8700-12 for an EPA(federal)ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) For existing ID number. C A L 0 0 0 1 1 fj _5 2 1 171 2. 1 am updating the mailing address and/or contact information only. 0 3. 1 am inactivating this ID number. N 4. 1 am reactivating this ID Number. Q 5. 1 am changing the business name only, no ownership change. (See instructions.) 6. Site/Facility/Business Name(include DBA): Mokelumne River Fish Hatchery/Ca Dept Fish and Wildlife 7. Site Location: 25800 N.McIntire Rd street Clements Ca 95227 San Joaguin city State Zip County 8. (a)Federal Employer ID Number 941697567 (b)Board of Equalization Fee Account Number is only required from g nerators Of 2neater than 5 tons per calendar year.) (See instructions.) 9. Mailing Address: PO Box 158 Street Clements Ca 95227 City State Zip (See instructions.) 10. Site Contact Person: William Smith First Name Last Name Contact Person Address: _25736 N McIntire Street Clements Ca 95227 city State Zip Contact Person Phone Number. (2os)759-3383 Fax Number: (2o9)759-3148 Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: williami.smithawildlife.ca.gov Preferred Primary Communication: E] Mall ffif—Email (See instructions.) 11. Legal Business Owner(not property owner): Ca Dept Fish and Wilt First Name Last Name Owner Address: 25800 N.Mcintire Rd Street Clements Ca 95227 AUG 2 4 2016 city State zip Owner Phone Number: (2og)759-3383 Fax Number. (2og 759-3148Pot Area Code Phone Number Area Code Fax Number v— (See instructions.)' 12. Standard Industrial Classification(SIC)Code for the Site: 0 2 7 3 (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,true,accurate an complete. SIGNATURE DATE 7/25/2016 NAME(print) William Smith TITLE FHM-TF PHONE 209759-3383 DISC 1358(5/29/15)