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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 t e or riot le ibl in ink. NEW NUMBER REQUESTS Check all that apply. 1 . I am applying for a new permanent California ID number as a hazardous waste : Generator ❑ Transporter Reason for a new number: A. ❑ Never had a number B . Business moved C. 11 Legal owner of business changed If your business generates greater than 100 kg of RCRA hazard us 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 ❑ 2. lam updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID number. ❑ 4. 1 am reactivating this ID number. Reason (please select one): A. ❑ Verification Questionnaire B. ❑ Other ❑ 5. 1 am changing the business name only, no ownership change. 6. Ste/Facility/Business Name (include DBA): Tawle Y er d :/ C 4T 7. Site Location : U 1 01 L • Fy-iyw 1 o #4 CSh'Ce4 kreet ,, ��,., C 'YDGrN�( V � ICG {� � SC? 0 Gin ( VAGi14ih City ®3 3y 3q `� State Zip Code Ir County 8. (a) Federal Employer ID Number C ,.7 / J (b) Board of Equalization Fee Account Number ((b) is only required from generators of greater than 5 tons per calendar year.) 9. Mailing Address: ' I Z lzl/em etl e / rif cl e Sir e G4 � '✓7 v Cit / 4 ' / State �t —7 Zi Code I/ 10 . Site Contact Person: L� � ) S � I mer / G id e / 4L First Name Last Name / Contact Person Address : 0 / z /nV ✓1l C!K'Le r S C71V2- City // --�7 /� State Zip Code Contact Person Phone Number: ( ®e ) �d � — l.l� / �/ / Fax Number: ( ) Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: L4 14zq110 O • C D Yk7 11 . Legal Business Owner (not property owner): Va, l'edl244e/ A - 112�i ,t!!� n-uoei C� rGLC CS L/� �i� i Glut 4iS> Owner Address: G� Street T / City State Zip Code Owner Phone Number: ( 9.M ) 1 � U7 / Fax Number: ( ) / rea Code Phone Number —I Area Code Fax Number 7 12. Standard Industrial Classification (SIC) Code for the Site: ` � (4-Digit Number) SII 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 and co�mp�llet�e. " , SIGNATURE (handwritten) G/ /I/V dy / `�� Date Name (print) G � I,S V r'l /e 117iG1L /�.. Title he /� Phone DTSC Form 1358 (09/18) Page 3 of 3