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State of California — California Environmental Protection Agency <br /> Department of Toxic Substances Control <br /> Office of Environmental Information Management <br /> PERMANENT STATE ID NUMBER APPLICATION <br /> Please a or rint le ibi in ink . <br /> FReason <br /> R REQUESTS Check all that apply. <br /> plying for anew permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter <br /> r a new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br /> s generates greater than 100 kg of RCRA hazardous waste other than those hazaxwj <br /> suparts (c) and {d) permonth, please complete Form 8700- 12 fora federaf EP.4 ID number. 0 61. 5 <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number: C A 1 (� NOV $ 2019 <br /> ❑ 2 . 1 am updating the mailing address and/or contact information only. <br /> ENVIRONMENTAL HF Al_ TH <br /> 113 . 1 am inactivating this ID number. <br /> PERMIT/SEP VICES <br /> 1K 4 . 1 am reactivating this ID number. Reason (please select one): A . ❑ Verification Questionnaire B. Other <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> 6 . Site/Facility/Business Name (Include DBA): <br /> 7. Site Location: <br /> Street <br /> Is LT <br /> City _ �,S Zip Code <br /> 8 . (a ) Federal Employer ID Number - 0St� �6 f t to County <br /> (b) CDTFA Account Number <br /> ((b) is only required from generators of greater than 5 tons per calendar year.) <br /> 9 . Mailing Address: (� (� ( � it <br /> Street <br /> C[ Mate Zip Code <br /> E <br /> 10 . Site Contact Person : Ci � <br /> First Name Last Name <br /> Contact Person Address: $_ + <br /> tre <br /> Cis <br /> City tate Zip Code <br /> Contact Person Phone Number: f ~' � Fax Number: (� } <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: <br /> I' <br /> 117Legal ess Owner (not property owner): N <br /> ess : <br /> Street City S Z de <br /> Owner Phone Number: - Fax Number: ( __ ) <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification (SIC ) Code far the Site: S <br /> —. (4-Digit Number) <br /> 13 . Certification: I certify under penalty of la e r ormafion on this document was prepared to the best of my knowledge and <br /> belief to be true, accurate an l <br /> SIGNATURE (handwritten) �� <br /> ® Date otg, <br /> Name (print) Title <br /> Phone <br /> DTSC Form 1358 (06119) <br /> Page 3 of 3 <br />