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Main Body Shop Record ID# PR0515092 <br /> May 20, 2019 Program: HW <br /> 1861 E Main St. Stockton, CA <br /> PHOTO 3: Completed DTSC form 1358 emailed to the DTSC while inspector was on site. <br /> State arCall/omla-Calllomla E-mnmenlal Prot-c-ion A,;n, <br /> PERMANENT STATEoa°e'°„°d""a,,,°"`�„u„�r � � <br /> NEW NUMBER RE Please, a ID NUMBER APPLICATION t- - <br /> UESTs Checkall lha,apply. YP°fel Ihl_I���, <br /> 1. 1 am applying for a new <br /> permanent California ID number as a hazaMnus waste.❑Gene <br /> sReason for a new number: q, ❑Never had a number B, <br /> your,, sans generates We591ness mouse rater Tra^spoRar <br /> ubpads(cl d(d)Per monfh�f base co00 kg o/RCRA hazardous to o C'O lelNl owner of business G,anga0 <br /> Mae mplefe .-8 <br /> rm 8700 12 b (her than Ihosa hezartbus wave IISf¢d In 00 CFR 261.5 <br /> r a fide2l EPq ID number, <br /> CHANGES TO STATUS OR INFORMAT ON FOR E <br /> For existing ID number: C A r.s (STING STATE ID NUMBER <br /> ID <br /> 2.I am updalmg the mailing address3Land/�onntact inform.ul only. <br /> 0 33. 1 am inactivating this ID number. / <br /> 04. lam reactivating this ID number.Reason(please select one): A. ,y <br /> 0 5. 1 am changing the business name only,no ownership change. IB Verification Questionnaire B. G Other <br /> 6.Site/Facility/Business Name(Include DBA); <br /> 7.Site Location:jb / A,,'t <br /> Ls>o,� cr i <br /> 8.(a)Federal Employer ID Numbs late <br /> rp Coa ry <br /> (b)Board of Equalization Fee Account Number <br /> (b)is only requiretl Irom generetors of greater than 5 tons per stand r year) <br /> 9. Mailing Address: <br /> Ire <br /> State ZI Code O <br /> 10. Site Contact Person: <br /> r 1-1..mul / Last 1J me <br /> Contact Person Address: //l (J <br /> gS�t <br /> Cl �C � p <br /> �J CIE <br /> State Zi Code / <br /> Contact Person Phone Number: ) (9/ C' �JQ Fax Number: <br /> rea (2p? <br /> ACode Phone Number c� Krea�C a Fax Nu bet <br /> Contact Person Business Email Address: lefatiAljotc <br /> i OQ <br /> 11. Legal Business Owner(not property owner): <br /> Name <br /> Owner Address: <br /> Street City State ZipCode <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:1 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 complete. <br /> SIGNATURE(handwritten) Date <br /> Name(print) Title Phone <br /> DTSC Form 1358(09/18) <br /> Page 3 of 3 <br /> t <br /> Tricia Dai, EHS Page 3 of 3 <br />