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��- LA --ILA - p State of California-Calif = C M C y ornia Environmental Protection Agency 0 —. Department of Toxic Substances Cc M Office of Environmental Information Manage PERMANENT STATE ID NUMBER APPLICATION NEW Please type or print legibly in ink. n• NUMBER REQUESTS Check all that apply. ❑ 1 in) am applying for a new permanent California ID number as a hazardous waste: Reason for a new number: El Generator El Transporter If your business A ❑ Never had a number B. ElBusiness moved C. 1:1 Legal owner of business changed subparts c generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261. ()and(d)permonth,please complete Form 8700-12 fora federal EPA ID number. CHANGES TO ST For exiATUS OR INFO ATION FOR A E STI S TE I NUMB R sting ID number: _ ❑ C A the 2• I am updatingmailing address and/or contact information only. ❑ 3• I am inactivating this ID number. p Our 4. lam reactivatin ru 9 this ID number. Reason(please select one): A. �berification Questionnaire B. Other < ❑ 5• I am changingf � the business name only,no ownership change. 3 < Ln °� ry 6• Site/Facility/Business Name(Include DBA): V e� 7. Site Location: 2 lC o ( ^ .� C 20 0- 8. (a)Federal Employer IDState Number p Code M (b)Board of Equalization Fee Account Number 0 required from generators of greater than 5tons per calendar year) O O C) O 9. Mailing Address: w � n r t , p — 3 O IV v llL State Code CD V 10. Site Contact Person: �l/`� lv� m First Name Last Name Contact Person AddreQ // tr t D ity !� State Z?Ccd�-p Contact Person Phone Number: — Fax Number: L_) n Are de Phone Number Area Code Fax Number O C ,•-r Contact Person Business Email Address: LA 11. Legal Business Owner(not property owner): N 3 e ` 3 O In City State Zip Code [D Owner Address: tre Fax Number: U 0, 0 Area de hone Number Area Code Fax Number owner Phone Num er: r rD (4-Digit Number) _.,..�-ao for the Site �, �