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State of California-California EnAronmeMel Protection Agency Department of Towc Substances Control <br /> Once of Environmental Information Management <br /> PERMANENT STATE ID NUMBER APPLICATION <br /> Please type or print legibly in ink. <br /> NEW NUMBER REQUESTS Check all that apply. � <br /> 1. 1 am applying for a new permanent California ID number as a hazardous waste>Ei Generator FJ Transporter <br /> Reason for anew number: A.`&l Never hada number B. ❑ Business moved C. ❑ Legal owner of business changed <br /> If yourbusmess generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261.5 <br /> subparts(c)and(d)permonth,please complete Form 8700-12 fora federal EPA ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number: C _A _ _ _ _ _ <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID number. <br /> ❑ 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,noownership change. <br /> 6. Site/Facility/Business Name(include DBA): Ke V in V'rtr_r <br /> 7. Site Location: 606 Ps ad IoA Q..F.I <br /> Street <br /> CA 95206 SAr zo. 4 <br /> City State Zip Code County <br /> B.(a)Federal Employer ID Number5S6- 8o-21 gin (b)COTFA Account Number <br /> ((b)is only required from generators of greaterthan 5 tans per calendar year.) <br /> 9. Mailing Address &)f). . Zaoa1 <br /> Street <br /> st <br /> O 1/ - State Zi Code <br /> 10. Site Contact Person: Ke.r.n \1 byY , S <br /> Firet Name `} Last Name <br /> Contact Person Address: 1801 <br /> Street <br /> CS " CA qSVD6 <br /> City State Zip Code <br /> Contact Person Phone Number: o9 ) 1..3N-311..tb Fax Number: (_) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address: 4 _G <br /> 11. Legal Business Omer(not property ovmer): k r <br /> Name <br /> Owner Address: lRvll.. '�or�a, I . 1 <br /> Street city State Zip Code <br /> Owner Phone Number: (2,LA) bb'$- 316o Fax Number: �) <br /> Area Code Phone Number Area Code Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: O 1 <L I (4-Digit Number) <br /> 13. Certification:I certify underpenaky of law that the information on this document was prepared to the best ofmyknow/edge and <br /> belief to be he (accurate endycpmpI he. <br /> SIGNATURE(handwrittenDate 11 ' Iq 114 <br /> Name(print) KPy 1 c. Title Ol Q,✓` Phone Zoo (.3 4. 3.7 L O <br /> DTSC Form 1358(06119) <br /> Page 3 of 3 <br />