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i <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 legibly In ink. <br /> NEW NUMBER REQUESTS Check all that apply, <br /> ❑ 1 . 1 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 269. 5 <br /> subparts (c) and (d) per month, please complete Form 8700- 12 fora federal EPA ID number. <br /> i <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE IDN MBERF <br /> For existing ID number: CA _ O <br /> ❑ 2 . 1 am updating the mailing address and/or contact information only, <br /> ❑ 3 . 1 am Inactivating this ID number. / <br /> WI1 am reactivating this ID number. Reason (please select one) : A. f2' Verification Questionnaire B. ❑ Other <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> I <br /> 6. Site/FacilityA3usiness Name (include DBA): W � I �� t /v. IF <br /> y <br /> 7. Site Locatlon: <br /> StreetVO 5AAw) <br /> s <br /> city State ZJp Code County <br /> 8. (a) Federal Employer ID Number ( � � / (b) Board of Equalization Fee Account Number -- <br /> ((b) Is only required from generators of greater than 5 tons per calendar year.) <br /> 9. Mailing Address: <br /> Sir It <br /> � 0 a <br /> city State Zip Code <br /> 10. Site Contact Person: _ 0 <br /> First Name `� Las� ts Name <br /> Contact Person Address : ! wa lUfl1/ff} � <br /> Street <br /> �. 0 � 5 / 0 I <br /> City State Zip Code <br /> Contact Person Phone Number: � � 6 Fax Number. ) 73 <br /> Area Code Phone Number , Area Code Fax Number <br /> Contact Person Business Email Address, <br /> � � ��(✓ ( � �/ • �! <br /> n F <br /> 11 . Legal Business Owner (not property owner): 1'-'�%UF7 ( <br /> t*✓� LM iJ.' amet� if & 0 ) � � d <br /> Owner Address' [� � <br /> Street, Qel63 City _, , State 65 7 &!) pde <br /> Owner Phone Number: l�� 365 * YFax Number: 9 (v j <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 and comp ete. <br /> (handwritten ) � �� <br /> SIGNATURE handwritten p Date p l <br /> Name (print) , � .� t , XID Title (LPCAj V 1) �� Phone � 4(r� � - / �( Iia � <br /> DTSC Form 1358 (09/18 ) <br /> Page 3 of 3 <br />