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State of California — California Environmental Protection Agency Department of Toxic Substances Control <br /> Office 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 . I am applying for a new permanent California ID number as a hazardous waste : ❑ Generator ❑ Transporter <br /> Reason for a new number: A. ❑ Never had a number B . ❑ Business moved C . ❑ Legal owner of business changed <br /> If your business 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) per month, please complete Form 870042 for a federal EPA ID number. <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number: C A 0Wft — <br /> ❑ 2 . 1 am updating the mailing address and /or contact information only. <br /> ❑ 3 . 1 am inactivating this ID number. ,. <br /> 4 . I am reactivating this ID number. Reason (please select one) : A . Verification QuestionB <br /> naire `* ._ [ Others E l <br /> ❑ 5 . 1 am changing the business name only, no ownership change. <br /> SL <br /> 6 . Site/Facility/Business Name ( Include DBA) : <br /> 7 . Site Location : 1 �L C f1i oI t <br /> �Street� C n 05 � Q?AJO AA avl <br /> City ® State Zip Code County <br /> 8 . (a ) Federal Employer ID Number �r� - 75 (b ) Board of Equalization Fee Account Number <br /> ( (b) is only required from generators of greater than 5 tons per calendar year.) <br /> auo S <br /> 9 , Mailing Address : ?5 <br /> treet /> /, od 5 <br /> city State Zip Code <br /> 10 , Site ContactPerson : d �`�0 � C a5 c. /( tA � <br /> First Name Last Name <br /> St <br /> Contact Person Address : <br /> Street <br /> City State Zip Code <br /> Contact Person Phone Number: ( Vcl ) _ Fax Number: (__) <br /> Area Code Phone Number Area Code Fax Number <br /> Contact Person Business Email Address : <br /> 11 . Legal Business Owner (not property owner) : <br /> Name <br /> Owner Address : <br /> Street City State Zip Code <br /> Owner Phone Number: ( ) Fax Number: ( ) <br /> Area Code Phone Number Area Code Fax Number <br /> F1 2 . Standard Industrial Classification (SIC) Code for the Site : , (4-Digit Number) <br /> 13 . Certification : I certify under penalty of law t at the information on t ' document was prepared to the best of my knowledge and <br /> belief to be true, accurate and p tel <br /> SIGNATURE (handwritten � ' /f Date <br /> t' ' � ' Title � l�cd}� �� PhoneC5.0q ) <br /> Name (print) ' ie <br /> a <br /> DTSC Form 1358 (09/18) <br />