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--a T1 N i] <br /> C7 = 07 0 0. <br /> W <br /> 0 - <br /> CO W <br /> 0 <br /> ow zZ Q <br /> Cn <br /> — v < O <br /> _ - 0 N O U) <br /> Department of ToxicSubSlana+^ <br /> L'orb h <br /> p.0.Sox 806.$acrertr <br /> ento.CA 3�� CO <br /> Slate of Coliroma-Calilomia Environmental Pmecilon Agency ER APPLICATION N <br /> * PERMANENT STATE ID NUMB _ _ c cn CSD <br /> I e Inslruchons caretullY. ortf. - Q <br /> Please type or neagy print in Ink.please re..i"w the hwts.dand cllek on Rs (Sea Insfrucpon>./ <br /> To check on the status o/YOU,re uasl, oto hll '.Ilw�uw. W O <br /> QUESTS Cneck all shat apDIY C7 <br /> I n !or a new permanent Califorrna ID number as a hazardous waste: ❑ Generator ❑Transporter <br /> 0 <br /> ,NEWNUMBERRE <br /> am apP yi 9 4 CFP O <br /> son ror new number: A. ❑ Never had a number B. ❑ Businessmoved CO legal owner of business ch0siness generates greater than ve kg of RCRA hazardous wase other than those hazardous waste listed in 0 _V <br /> subparts(c)and(d).per month,complete Form 8700-12 ror an EPA(redaraQ ID number. - _ _)I 0 <br /> jhva m I D <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUCqlMBE/R1 I _ (9 <br /> For existing ID number: C A — L=A -12- —L +--1— O 011 <br /> r ❑ 2. 1 am updating the mailing address and/or contact information only. N <br /> O <br /> 91 3. 1 am inactivating this ID Number. B. Cl Other (D Ul <br /> ❑ 4. I am reactivating this ID Number. Reason(please select one): A. ❑ Verification Questionnaire <br /> ❑ 5. I am changing the business name only,no ownership change. M <br /> (See instr]�de'a <br /> D <br /> O p1cr2 GsfR <br /> F7n <br /> Site/Facility/Business Name(Include DBA): 0 <br /> 105 N LO I( '' Y <br /> StreetCi old ('/� �5 2�� - SIIJ70Q� "I/State eeCounty i r 0City ll r,r� O tDyer ID Number V�'D�t V�D 0 (b)Board of Equalization Fee Account Number O <br /> ((b)is only required from generators of greater than 5 tons per cale <br /> (See instructions.) <br /> 9. Mailing Address: C &-) CV L?—' <br /> L? <br /> Stree� (�� J'7 /�✓ <br /> City <br /> State Zlp <br /> (See instructions.) <br /> -r <br /> rC..ntact <br /> ite Contact Person: A iJ t, <br /> first Name Last Name <br /> ontact Person Address: �I C�) !1i I }j-/ �) <br /> St�*i 0Z IT aLt <br /> City State Zip <br /> Person Phone Number: ( )76 r_�1 Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> ntact Person Business Email Address: Preferred Primary Communication. ❑ Mail ❑ Email <br /> ' (See instructions.) <br /> 11. Legal Business Owner(not property owner): /L L rJ ( FtTt <br /> - <br /> Owner Address: 1 S 0 lJ 111y C�fig`! cIry / State ZIP <br /> Owner Phone Number: (XL�l) ��� Fax Number: ( ) <br /> Area(Cod Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: _ _ (4-Digit Number) (See instructions.) <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 /> r I � <br /> SIGNATURE __ J IYII // nn DATE <br /> Q <br /> NAME(print) F 't4,0 ��ATr�XI-74 TITLE//- W N <br /> JO <br /> DTSC Form 1358(01/17) (D <br /> Q <br /> W <br /> aD1 <br /> o O <br /> Ul <br /> Ul N <br /> 00 <br />