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(See instructions.) <br />0c1 1- (4-Digit Number) <br />12_ Standard Industrial Classification (SIC) Code for the Site: <br />it I 5SUE C A L 0 Lk M lo <br />State of California — California Environmental Protection Agency Department of Toxic Substances Control - I-IWMP <br />P.O. Box 806, Sacramento, GA 95812-0806 <br />PERMANENT STATE ID NUMBER APPLICATION <br />Please type or neatly print in ink. Please review the line-by-line instructions carefully. <br />To check on the status of your request, go to www.hwts.dtsc.ca,gov and click on Reports. <br />NEW NUMBER REQUESTS Check all that apply. (Se.e instructions.) <br />E] 1 I am applying for a new perm)anent California ID number as a hazardous waste: EI Generator 0 Transporter <br />Reason for new number A J Never had a number B. 0 Business moved C. 0 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, complete Form 6700-12 for an EPA (federal) ID number. <br />1 -3-S0 E YOSeAnt kw- <br />Nisavti- eccK Cr (1533(0 Soen Sockotv <br />City State Zip County <br />(a) Federal Employer ID Number II -3014 (b) Board of Equalization Fee Account Number IN 101- L5go 2.4 <br />((b) is only required from generators of greater than 5 tons per calendar year.) <br />Site Location: <br />Street <br />RA loon c ct 3(0 (.0 Street, cP <br />City State ZIP <br />Mailing Address. 20 6 0 x 3 to (See instructions.) <br />CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) <br />For existing ID number. C A <br />2. I am updating the mailing address and/or contact information only. <br />3. I am inactivating this ID number. <br />4. I am reactivating this ID Number. <br />5. I am changing the business name only, no ownership change. <br />instructions.) <br />6. Site/Facility/Business Name (Include DBA): Foo \ r cc O,n1 otif <br />10. Site Contact Person: BOO( \MAU( <br />First Name Last Name <br />F0 oX <br />Street Ron CA <br />City State, Zip <br />Contact Person Phone Number (2.01) 5CACI - 5360c) Fax Number. (209! 2.39-3500 <br /> <br />Area Code Phone Number 2_irea Code Fax Number <br />Contact Person Business Email Address: • • A al r <br />Preferred Primary Communication: 2''Mail <br />Owner Address: <br />First Name <br />)oY\ -2)3 <br />WoLkex <br />Last Name <br />(See instructions. <br />11 Legal Business Owner (not property owner): <br />Strt co NA <br />City State <br />Owner Phone Number: (2.A 5SCV'tg 'b <br />Area Code Phone Number <br />CA elS3(D(0 <br />Zip <br />Fax Number: (20q <br />Area Code Fax Number <br />26`1- 3 Soo <br />Email <br />GI S 500 <br />(See instructions.) <br />Contact Person Address: <br />(See instructions.) <br />ormation on this document was prepared to the best of my knowledge and <br />DATE aitlh (0 <br />PHONE CUCI)SfiCi- ii•W <br />DTSC 1358 (5/29/15) <br />13. Certification: / certify under enalty if law thct the <br />belief to be; true, accurat; and c pie. <br />or r Walke r TITLE biljne,r <br />SIGNATURE <br />NAME (print)